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(f) Whole grain or enriched breads and cereals: two or more servings. (9) Butter and other fats with each meal.

(h) Additional foods in amounts to meet the patient's caloric needs and to make meals appetizing and satisfying.

(i) Iodized salt as a seasoning. It is not sufficient merely to prepare a variety of good foods at each meal if no consideration is given to individual food preferences and individual abilities to consume the food. Many elderly people, particularly those who are somewhat senile, will prefer to make a meal from one type of food. Personnel who understand the situation can see to it that dietetic correction can be made at the next meal.

2. Food should be prepared by accepted methods to conserve maximum food value and to produce maximum palatable and attractive meals.

3. Self-explanatory. 4. Self-explanatory. 5. Self-explanatory.

6. Cyclic menu planning is acceptable, taking into consideration the season of the year and also the length of the cycle. It is felt that cycling should not be of less than 3 weeks, preferably 5 to 6 weeks. Monotony is to be avoided. 7. Self-explanatory.

8. This question has many ramifications, including physical ineptness at eating (e.g., the arthritic patient, the patient with a stroke, etc.), the patient who prefers certain types of food to the exclusion of a well balanced diet, etc.

9. Facilities should be equipped to serve a low salt (low sodium) diet and also uncomplicated diabetic exchange diets.

10, 11. It is felt that nursing home patients should have a minimum of three meals per day. Should it be the policy of the homes in certain areas to have more than 14 hours maximum between evening and morning meal, then supplemental feedings should be served in the evening when requested.

12. Patients should be weighed monthly wherever possible, weight recorded with significant changes reported to the attending physician. When unable to weigh a patient, measurements of bust, waist, hip, ankle and calf may provide a criteria of weight change.

C. Housekeeping:
1. Self-explanatory.

2. This will require a subjective answer and will depend in part upon the perspicacity of the surveyor.

3. Again, this is primarily subjective in character. The smaller homes will attempt to duplicate the atmosphere of the well-organized and well-run private homes. The larger facilities, particularly those that offer skilled nursing care will, in many instances, more closely resemble a clean and sanitary small hospital. The general atmosphere should reflect those services which the facility is offering. 4. It is anticipated that not all facilities should or will have a communal eating

The situation will depend upon the type of facility. Recreation rooms and other communal rooms are desirable so that the elderly patients and guests may have an adequate area in which they may fraternize and enjoy each others' company.

D. Sanitation :

1. Rodenticides and insecticides : Harmless compounds should be used whenever and wherever possible in the extermination of rodents or insects.

2. Sanitary food handling : Employees should be adequately instructed in acceptable and sanitary food handling practices.

E. Safety measures :
1. All evacuation plans should include the following information :

(a) What to do in case of an emergency.

(6) When the evacuation plan is to be placed in operation during a specific emergency.

(c) Where evacuation equipment is located and what routes are to be taken.

(d) How evacuation plan operates and who is responsible for each phase.

(e) Why each employee is required to know his task in relation to entire. plan. 2. First aid supplies for emergency care should be maintained in a place known and readily available to all personnel responsible for the health and wellbeing of patients.


3. It is felt that all personnel should be aware of ordinary household accident prevention measures (examples : vacuum cleaner cords, mop handles, etc., being left in pathway of patients and other personnel).

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The fee schedule may be adjusted to meet the needs of the individual State nursing home associations.

Mrs. BAIRD. The idea was not new. Dr. Ernest P. Boas suggested such action in his book "Chronic Disease, the Unseen Plague,” published in 1940, 21 years ago. The Nursing Home Associations of California, Colorado, Connecticut, Illinois, New York, and Wisconsin had developed individual State accreditation programs. Connecticut and Milwaukee County, Wis., had progressed to inspection of facilities and certification of accreditated homes. However, the ineffectiveness of many totally unrelated and unrecognized accreditation programs was evident to leaders in the nursing home field. This led to a study of the problem by the American Nursing Home Association and subsequent adoption by that organization of a national program.

I might deviate briefly and explain that we are in the process of forming a wholly owned, nonprofit subsidiary of the American Nursing Home Association to be called the Joint Council for Accreditation of Nursing Homes and Related Facilities. It will be composed of the American Medical Association, American Hospital Association, American Dental Association, American Nurses Association, and our own organization. On the State level we have provided for representation from the reimbursing agencies and the licensing agencies as well as third party payment on independent insurance companies.

I will not take the time of the committee to explain the workings of the program, as time is limited.

By adopting a national accreditation program the American Nursing Home Association has proved to the public and others in the health field that they recognize the need for some evaluation of quality, some guide to those who are in need of and must select specialized services. In the coming years one will be able to use the phrase "intensive nursing home care” and its meaning will be exact, in the New England States of Massachusetts, New Hampshire, and Connecticut, in Michigan, in Oregon, indeed in all the States.

In the formation of its accreditation program the American Nursing Home Association was gratified by the encouragement and interest shown by other groups in the paramedical field. The assistance of the Joint Council To Improve Health Care of the Aged was of particular value.

This is what the American Nursing Home Association is doing to improve standards in nursing homes, accreditation as well as many of the other projects related by previous speakers. Accreditation is a great step forward for all nursing homes and it deserves the cooperation and support and welcome of all.

Senator SMITH. Thank you very much, Mrs. Baird. Let me just ask one question on your standards. Does your program call for written standards?

Mr. BAIRD. The American Nursing Home Association has a standards committee which met with the U.S. Public Health Service and helped formulate the standards which are supposedly used by all States as a basis for their licensing program.

These standards have also been used in our accreditation program. They have been raised in some States because some States require 24hour licensed nursing staff and others only require supervision by a registered nurse. We have tried to adapt our accreditation program to the licensing requirements of all the States.

Senator Smith. In what percentage of the States do you find that program going forward at the present time?

Mrs. BAIRD. At the present time we are waiting until all of the other groups are in and the new national program is functioning. We had 110 homes surveyed prior to that strictly on a State level. Of those approximately 43 homes had been accredited but certificates were not awarded since the program was just revised this past October.

Senator SMITH. Let me say at this time, I think that as your program progresses if you could make reports available to this committee I think it would be a great help to us.

Thank you very much, Mrs. Baird.

Our next witness will be Mr. Miroslav Kerner, Director of Services to the Aged, Jewish Family and Children's Service of Boston.


AGED, JEWISH FAMILY AND CHILDREN'S SERVICE, BOSTON Mr. KERNER. Mr. Chairman and members of the committee, I am Miroslav Kerner and I am head of the Services to the Aged, Jewish Family and Children's Service, here in Boston.

I thought it my duty as a practicing social worker to voice a warning against singling out too much only one single problem such as the nursing care for the aged of the entire complex of the care for the aging. I want to give an example of what happened in Massachusetts in the last, let's say? years.

In 1954 the basic public assistance nursing home rate in Massachusetts was $28 a week, and in 1961 this rate is $46.20 a week, which represents an increase of 65 percent.

Senator SMITH. Would you repeat those figures again.

Mr. KERNER. Yes. The basic rate in 1954 was $28 a week and in 1961 the rate is $46.20. That represents an increase of 65 percent.

The basic public assistance rate in rest homes, which are also licensed in Massachusetts, was in 1954, $25 a week and is now in 1961, $29.75; in other words, an increase of approximately only 12 percent.

Now this had some very unfortunate results. I would like only to interject here that although the Nursing Home Association claims that the nursing home operations are quite expensive, on the other hand apparently during the past 10 months, they were quite profitable business because their number increased in the period between 1948 and 1957 twice. In the last 2 years, for instance, there were in the city of Boston only 13 new nursing homes opened as against only 1 rest home.

In the town of Newton, for instance, we had in 1959 9 rest homes and 14 nursing homes. In 1961 we have in the town of Newton 1 rest

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home and 17 nursing homes. We do not have in the entire Greater Boston area a single Jewish rest home.

I think that this is the result of our effort when we focus on only one single type of care for the aging. We push too many older people into nursing homes. The aging need all kinds of facilities of arrangements for living such as their own apartments, rooms, rooms with kitchen privileges, room and board, rest homes, convalescent homes, homes for the aged, and then finally nursing homes and private hospitals for custodial care.

I thought that it may be important, that we should not forget that the care for the aged should be balanced and that all these programs should get the necessary attention, both financially and licensewise.

Senator Smith. Thank you very much, Mr. Kerner, for your testimony. It has been most interesting and I know that it will be helpful to us.

Mr. KERNER. Thank you.
(The prepared statement of Mr. Kerner follows:)



My name is Miroslav Kerner and I am the head of the Special Services to the Aged of the Jewish Family and Children's Service in Boston. I am testifying in my capacity as a social work practitioner.

It is very encouraging to see that the Special Committee on Aging is spending so much time on the problems of the aging and on the specific problem of nursing home care, which is one of the most pressing and difficult in the entire area of care for those aged persons who cannot any more continue their independent way of life. Nevertheless, I thought it important to raise the voice of a social work practitioner in calling the attention of the committee to the fact that such problems as the nursing care should and have to be considered within the scope of the integrated care for the aged. If only one problem is singled out and improved without necessary regard to the other needs of the aged, the planning for the care of many other aged persons who do not need nursing care is becoming more difficult.

In order to illustrate what can happen I would like to point out our present situation in Massachusetts, particularly in the Greater Boston area. We have in our State one of the best public assistance programs for the care of the aging which is reflected both in the high allowances in the public assistance budget and also in the excellent medical care which is being provided for the aged population of Massachusetts on public assistance. Being aware of this situation our public welfare department increased several times the rates for the nursing home care since 1954. The basic rate in that year was $28 a week. After several raises it is now at the level of $46.20 a week which represents an increase of 65 percent.

During the same period of time the basic rent in the rest home which provides care for ambulatory residents has been increased from $25 a week in 1954 to $29.75 in 1961, and that only very recently. The increase amounts to approximately 12 percent and, in my opinion, is very belated and also very inadequate.

The inadequacy and poor correlation in the increases of the fees in these different types of care for the aged is proved by the development of nursing homes and rest homes in many communities in Massachusetts. In the city of Boston proper there was only one rest home opened since 1959 as against 13 nursing homes, out of which some have quite a large number of beds. In the town of Newton, for instance, there were nine rest homes and 14 nursing homes in 1959. Two years later, in 1961, there is only one rest home in Newton, but 17 nursing homes. Although the proprietors of privately owned nursing homes claim that the fees paid for their residents on public assistance are low, it seems that ownership of a nursing home is quite a lucrative business, or at least was, according to the standards required in the past, because the number of nursing homes in Massachusetts in the period between 1948 to 1957 doubled and since that time still continued to increase. Probably this increase will slow down as higher standards are being required by the licensing authority and this is all to the better.

The results of the substantially increased rates for the nursing home care without a simultaneous improvement of the rates in the rest homes made the operation of a nursing home commercially much more attractive. Not only did the number of rest homes diminish but the quality of their care suffered. Most of them serve meals on trays as they do in nursing homes. There is inadequate space for social activities of the residents so that lay persons cannot very well differentiate a rest home from a nursing home. The low rate for rest home care makes it also much more difficult for nonprofit organizations to operate rest homes as they have to bear a burden of a large subsidization.

As social workers we would like to provide for every aging person the kind of living arrangements which are best suitable for him, or her, or for the aged couple. There is an entire scale of living arrangements which should be all available in every community, especially in a metropolitan area. At the present time, unfortunately, there is not a single Jewish rest home in the Greater Boston area.

Many of the elderly persons, Jewish and non-Jewish, are forced into entering nursing homes where they are fast deteriorating both physically and emotionally to the level of the majority of the bed-ridden patients living in these nursing homes. This is very unfortunate and we would like to see that some of them should be enabled to live in their own apartments, either in private houses or in publicly supported housing developments. Other adult persons can continue to live in individual rooms either in lodging houses or with families, if they are still capable of eating outside and do not require special diet. The next group of elderly may be satisfactorily placed in rooms with kitchen privileges or in room and board arrangements in cases where eating in restaurants would be too difficult or is not recommendable by their medical needs. When neither of these arrangements can be used, but the old person is ambulatory, a foster home can be a very highly recommendable solution and if even this could not be provided such persons should be offered an opportunity to live in a rest home where they would be served meals in a dining room and would have adequate space for socializing in a lounge or similar room where they could congregate. Such homes can be located close to the downtown areas and do encourage their residents in participation in the community life as their residents are not confined to their premises. A small rest home for 15 up to 30 residents is a much healthier living arrangement than a large home for the aged with a population of several hundred persons which constitutes a tremendous need for readjustment on the part of persons who were used to independent living and are now forced into a group accommodation with many restrictions on their liberties. Homes for the aged should be a matter of last choice when all other placements are unsuitable.

I would like to emphasize again that the nursing home care is very essential for the needs of the elderly citizen, but providing nursing home care which would be much superior to the other possible placements would only aggravate the entire situation in the field of the care for the aging and probably would again force many people into nursing homes who should not be there and should be encouraged to continue an independent way of life.

Senator SMITH. Ladies and gentlemen, I am very happy now to welcome back to the statehouse a man who has spent a great deal of time right here in this very statehouse, a man who you all know has spent a great deal of his life serving all of the people of Massachusetts, and a man who is sincerely interested in the great problems of the aging that face us today. I am very happy to present to you my distinguished colleague, Senator Leverett Saltonstall, whom you all know so well.

Senator SALTONSTALL. Senator Smith and ladies and gentlemen, first may I say I appreciate very much Senator Smith asking me to join him here for a few minutes today. As he says, I have sat in this room a good many times, at this desk all the way up and down the line here, and occasionally in front over the years. I cannot see that the room has changed very much in appearance but I am glad to have a distinguished colleague sitting as the chairman. I am sure that he will give very interested and pertinent attention to the facts that you ladies and gentlemen bring out on this very important subject.

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