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Mr. RICKLER. I would say, basing it upon patients received from welfare or public assistance patients, it runs the gamut of anywhere from $4 a day anywhere up to $7 a day. New York City pays, I believe, $180 to $200-some per month, which, I believe, is about the highest rate. Of course, their costs are higher for operation. And throughout New York State I have taken that up with the welfare, and we try to maintain an average of $5 per day. We cannot make any money on that basis. It is just about what it costs us to operate on that basis per day. But, of course, again, gentlemen, it varies with the community. In some communities it is lower. But generally the standard throughout the country, rents and other expenses, it runs about, for private patient care, from $7 a day up. Am I correct in that statement.

Miss SIEGEL. That is correct.

Mr. RICKLER. I do not want to make a statement I am not quite certain of, but I have made studies of figures, and that is what it runs.

Mr. YOUNGER. Thank you.

Mr. HESELTON. In connection with the language changes that have been suggested, I notice that you use the phrase "proprietary nursing homes” while your association is “registered nursing homes." I am wondering in the use of any language, would that include homes operated, for instance, by Sisters?

Mr. RICKLER. No. We only take private homes in our association, and while we say registered may I explain that in using that name, before we accept any home in our association we see that they comply with the standards that we have set up, that we believe are minimum standards. And on our advisory committees we have members in those communties, I think in practically every community, of the Welfare Department, of the Hospital Association, where we can secure a member. That is why we call it registered nursing homes.

Mr. HESELTON. In terms of any changes in the bill, which would be the phrase?

Mr. RICKLER. Proprietary, meaning privately operated.

Mr. HESELTON. Would that cover those operated by religious organizations?

Mr. RICKLER. No. They are not proprietary. But, of course, sir, they come within the purview of 7341, or they could come within the purview of this bill too.

Mr. HESELTON. If you used “nursing homes” that would cover all of them?

Mr. RICKLER. That would cover all of them. But we are proprio tary because we are operated on individual private capital, private investment.

Mr. HESELTON. You mentioned the standards.
Mr. RICKLER. Yes, that is part of our constitution.
Mr. HESELTON. Do you have any briefs you can furnish us on that?

Mr RICKLER. No. Is that in our code? Our standards that we have, Mr. Case ?

Mr. CASE. Yes, we have a qualifying sheet.

Mr. RICKLER. We would be glad to leave it with the clerk, what our qualifications are.

Not that I am here to laud our own association, but we have honestly made and do make a sincere effort, and any violation is subject to being removed as a member of the Nursing Home Association.

Mr. HESELTON. Thank you.
Mr. RICKLER. Thank you, sir.
The CHAIRMAN. Are there any further questions?

Will you tell me something of the organization of the National Association of Registered Nursing Homes, particularly with reference to how many it consists of, how many States are represented, whether you hold national meetings, how the officers are elected, and particularly with reference to whether there is any other national organization of a similar kind.

Mr. RICKLER. May I answer that, sir. There is another organization known as the American Nursing Home Association, who appeared before this committee on H. R. 7341, who were meeting in Washington at that time.

The CHAIRMAN. That is what I was endeavoring to find out, whether this was the same organization that met here at that time.

Mr. RICKLER. No, we are not. We are not the same organization. May I say this, that our organization is primarily organized on a county and State basis. In New York State and in most of the States membership in the State is automatically membership in the national, and part of the funds raised are contributed toward the national or ganization. We have membership in 33 States. We meet regularly, quarterly, and we hold national conventions each year. Our national convention is in Columbus, Ohio, is that correct, for this year?

Miss SIEGAL. Not yet.

Mr. RICKLER. I know we are supposed to meet this summer in Columbus, Ohio.

Miss SIEGAL. It was in November.
The CHAIRMAN. Do you publish reports of your annual meetings?
Mr. RICKLER. Yes, sir, we publish a publication.
The CHAIRMAN. You might send to us your last annual report.
Mr. RickLER. We will be happy to do so.

The CHAIRMAN. So we can get some idea of the organization and how it operates.

Miss SIEGAL. We will be very happy to do so.

The CHAIRMAN. Furthermore, you have made suggestions for amendments to this bill. Instead of pointing out where the amendments should be made would it be possible for you to suggest amendments? In other words, to be more specific ?

Mr. RICKLER. I believe we could be more specific in the amendments that we would suggest, but, again, from your great number of years of experience, all of you gentlemen, in bills, and my previous work in bills, we feel the only thing that we ask to be included is that loans be made available to the proprietary nursing home. As the bill is at the present time, without going into a prolonged discussion, we feel that it only covers nonprofit organizations and nonprofit medical facilities. We have no objection to other features of the bill. It is only to the extent of the medical facilities to be included known as the nursing homes.

Now we would be glad to draw recommendations and forward them to your committee, but I believe we discussed that this morning, did we not, sir, prior to our coming in, and I believe you understand our position in the matter.

The CHAIRMAN. Very well. Are there any further questions?

If not, we thank you for your appearance here today, Miss Siegal, and the statement that you have made to the committee, and also the statements that have been made by your general counsel.

Mrs. Hopkins, are you expecting to speak today, or is this the statement that you would otherwise have given?

Mrs. HOPKINS This is the statement of our association. I am not prepared to speak.

The CHAIRMAN. I want to say for Mrrs. Hopkins that she has, for a period of time, shown a very great interest in the work of this committee in this particular, and she has shown her interest in more ways than one in connection with the inclusion of nursing homes. We would have been very glad to have heard from you, Mrs. Hopkins, but we assume that since the president has spoken that carries the weight of the organization and we have had the benefit of the statement.

Mrs. HOPKINS Thank you very much, Mr. Chairman. If you do have extra time Mr. Manning, from a nursing home in Virginia, would like to have something personally to say later.

The CHAIRMAN. Will it take very long?
Mr. MANNING. No, sir.

The CHAIRMAN. Very well. Step right up front, sir, and give your name and residence and what, if any, position you occupy and in what capacity you testify. STATEMENT OF THURMOND W. MANNING, PORTSMOUTH, VA., FIRST

VICE PRESIDENT, VIRGINIA ASSOCIATION OF NURSING HOMES

Mr. MANNING. Thank you, Mr. Chairman and members of the committee, my name is Thurmond W. Manning. I operate and direct a nursing home in the city of Portsmouth, Va., and I am speaking also as vice president of our Virginia Association of Nursing Homes.

We certainly would never oppose anything that is to enhance the care of the patient. Regardless of how much and to what extent we would discuss this problem, our every though should revolve around the care of the patient placed in our charge.

The next consideration is how can that be done most economically? It seems to me, Mr. Chairman, that we have the nucleus for the care of our aged, but our people do need help. For the most part, the nursing homes were set up in the old mansion type buildings, and certainly I feel that, for the most part, the people that are operating these nursing homes are not primarily interested in financial gain.

We are in a difficult situation in that we are, in a sense, doing business in the medical profession, and of course, as we all know, to be able to continue in a business we must show a profit. To show a profit we must advertise. Yet we were taught at Bellevue that in the medical profession we could not advertise, but that we could educate.

If the proprietary nursing-home operator were to be granted this loan, as proposed, on a long-term basis, it certainly would help the economic situation, if we could get the loan on a long-term basis at a low rate of interest. We certainly would be able to pass that saving, so to speak, on to the patient, and I certainly hope that you gentlemen will see fit to help us because we are most desirous of doing the thing that we have set out to do. It seems to me that the very heart of our American economy is based on the desire of the individual to take care of himself.

I thank you very much.
The CHAIRMAN. Are there any questions, gentlemen?
Mr. HESELTON. I have one question.

What is the general situation in terms of supervision by licensed physicians?

Mr. MANNING. Mr. Heselton, it would be almost impossible to pinpoint the responsibility or delegate the responsibility to any one organization or group of people. We need teamwork. We need cooperation, cooperative efforts between the nursing-home administrator and the health, welfare, and educational authorities. The responsibility would lie with all of us.

Mr. HESELTON. I have in mind that as the bill is drawn it refers in one portion to medical rehabilitation and convalescent facilities in which the patient care is under the professional supervision of persons licensed to practice medicine in the State. And at least as far as I know there are a good many instances where a person is not in the care of a doctor but still needs the services that are provided for in these nursing homes. Is that true?

Mr. MANNING. Mr. Heselton, in our State it is a prerequisite that the patient be admitted to the nursing home by the doctor.

Mr. HESELTON. The admission is under the doctor's supervision, but is there any treatment necessary by a doctor or any supervision by a doctor once the patient has been admitted?

Mr. MANNING. Yes, sir. There is a clinical chart kept on the patient, and the patient is not given an aspirin except by order of the patient's physician.

Mr. HESELTON. May I ask counsel, is that true generally speaking over the country?

Mr. RICKLER. Yes. Of course, we must keep records the same as hospitals, that is, in all members of our organization. I cannot speak for some States because we are not familiar with them. But just as the question was answered by the witness, they cannot be admitted unless they are admitted by a doctor. They have got to be under the supervision of a doctor. The welfare patients are under the supervision of a doctor. A medical chart must be kept. There is a regular provision the same as set up by the hospital association. The patients are signed in and signed out, the doctors sign them in and sign them out. As far as the medical aspects of the nursing home are concerned, I think, gentlemen, that the best way I can describe it is from my experience as counsel, and my own observations. This is the part of hospitalization where a patient is not in need of active medical care in most instances. The patient is, just what the word connotates, convalescent, and in the field of geriatrics, which, of course, is one of the reasons for this bill today, we are recognizing the increase of the age of people in this country and that facilities do have to be provided for them. But when they become seriously ill they should be transferred from the nursing home to the hospital. That is our belief and that is our standard and that is our code.

The CHAIRMAN. Are there any further questions?
If not, we thank you for your appearance here today.

Mrs. HOPKINS. Mr. Rickler made a statement a while ago that I think was not clear. He said in the National Association of Registered

Nursing Homes we only had proprietary nursing homes as members. That is true as to active members, but as affiliate members we have the others who want to come on. We feel that the proprietary nursing homes have problems peculiar only to proprietary groups, so they are the active members; the nonprofit nursing homes who would like to profit from our experience and from the things we have in our meetings, we are glad to have them, but they are not full-fledged members.

The CHAIRMAN. Do I understand, Mrs. Hopkins, the use of the term "proprietary” does not cover the entire field of nursing homes?

Mrs. Hopkins. That is right.
The CHAIRMAN. What term would you use?
Mrs. HOPKINS. We say nonprofit and proprietary, down in Virginia.

Mr. RICKLER. They can be affiliated but not active members. I thought, in response to Mr. Heselton, he had asked me who were the active members of the organization.

The CHAIRMAN. We thank you for your appearance today and the information you have given to the committee.

Miss SIEGAL. Thank you, Mr. Chairman.

The CHAIRMAN. The next witness is Mrs. Evelyn G. Stone, chairman of the standards committee of the Missouri Association of Licensed Nursing Homes.

Mrs. Stone, we will be glad to hear from you and those for whom you speak. You may proceed.

STATEMENT OF MRS. EVELYN G. STONE, ST. LOUIS, MO., CHAIR

MAN, STANDARDS COMMITTEE, MISSOURI ASSOCIATION OF LICENSED NURSING HOMES

Mrs. STONE. Mr. Chairman and members of the committee, my name is Evelyn Stone. I am here today through the kind cooperation of my Congresswoman, Mrs. John B. Sullivan, and with the permission of Mr. Wolverton. I am the past president of the Missouri Association of Nursing Homes, serving in that capacity for two terms. Until recently I have headed the standards committee of this organization. I am a registered nurse and have owned and supervised a private nursing home in St. Louis, Mo., since 1935.

Through my experience with the Missouri Association of Nursing Homes and working with the public officials, professional groups

and many committees that have studied the needs and facilities for the care of the chronically ill, I want to give you my views as to the application of this bill to the field in which ☺ have worked.

First of all, I am wholeheartedly in accord with the intent of the bill as I understand it. My remarks shall be concentrated on the need of facilities for convalescent care and chronic illness. The fact is already established that general hospitals cannot provide enough beds for this purpose. At the same time in my experience there are many professional people who see the problem and would like to help the situation but who are deterred by the impossibility of securing adequate financing for the building and equipping of such institutions.

Many people have attempted to aid in the care of the chronically ill by operating nursing homes. Lack of funds to erect desirable buildings and provide proper equipment have resulted in bringing about

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