After careful study of the existing facilities for conversion into patient care and clinical areas an because of the possible difficulty to recruit required staffing, we have determined that 275 beds could be established. We propose that at least 90 of these beds must be staffed and equipped for the acutely ill. type of service and care established also has a great bearing on our ability to recruit and retain professional personnel.

The

At the present time, we maintain an average daily number load of 940 with our 1,025-bed domiciliary. Members requiring short-time medical and nursing care are presently admitted to our domiciliary infirmary. Those requiring definitive hospital care are transferred to a VA hospital. This includes transferring those requiring intermediate care. In our proposal the domiciliary infirmary would be eliminated and would become a part of the 90 beds for the acutely ill. This is emphasized, since there would be quite a demand for both acute and intermediate care of our present domiciliary member population.

We will be happy to furnish any additional information that you may desire.

WOOD, WIS.

Building No. 43 with 226 beds could be activated in the early part of fiscal year 1965 (about 30 months from now); balance (800 to 1,000) could be activated in fiscal year 1968 (about 66 months from now). These possibilities and the timing relate to the construction of a new hospital here which is now in progress.

The plans would necessitate VA policy decisions. The completion of the new hospital would permit release of existing hospital buildings for accommodation of domiciliary activities. The plans, in part, would be for consideration of the renovation of the best of the domiciliary buildings for the 800-1,000 nursing-care beds. The 226 beds above referred to are in a hospital building somewhat remotely located from the main hospital. This building will also be vacated when the new hospital is completed.

Another possibility, perhaps the most practical and most economical, would be to convert for nursing care the present main hospital building when it is vacated. This would put the nursing-care facility adjacent to the new hospital building thereby affording flexibility in the utilization of staff. In this event, the best of the existing domiciliary buildings plus building No. 43 could be used for domiciliary activities.

Assuming that authority would be available for nursing care by the VA, the following agency policy decisions would still be involved:

(1) Use of domiciliary buildings, eventually to be vacated, for nursing care instead of abandoning them.

(2) Use of building No. 43 for nursing care instead of creating a separate domiciliary activity in this building.

(3) Use of existing main hospital building when vacated as nursing-care facility instead of domiciliary activity.

The above is not submitted as a firm opinion or a recommendation that the VA should assume responsibility for nursing care for veterans. The statement is merely an expression of possibilities if legislative authority should be developed.

SUMMARY

Re: Subparagraphs (1), (2), and (3):

Plan under (1) and combined would provide 226 beds in fiscal year 1965 and 800 to 1,000 in fiscal year 1968;

Cost: Renovation, $7 million; equipment, $75,000; renovation cost includes projected cost of renovation which would still be required in existing hospital building needed for conversion of domiciliary,

Plan under (3) would provide 800 to 1,000 beds in fiscal year 1956;

Cost: Renovation, $2 million; equipment, $30,000.

Cost estimates are not based on detailed study because of time limitation.

LETTER FROM ROBERT A. EVERETT, CHAIRMAN, SUBCOMMITTEE ON INTERMEDIATE CARE

FEBRUARY 25, 1963.

Assuming the existence of authority and availability of funds, the subcommittee would like to know how many nursing-care beds you could provide and staff at your installation and the cost of renovating or modernizing existing structures (including equipment), but not involving the construction of any new buildings. Please indicate your reply in the space provided.

Number of nursing care beds which can be provided....

Cost of renovation..

Cost of equipment.

Estimated per diem cost

Estimated time (months) to activate nursing care beds.

Letter sent to stations listed on page 151 and the following who submitted negative replies:

Mr. TEAGUE of Texas. As you say, there will be further study by this subcommittee. May I ask one question? You state on the first page:

"For example, there are now in VA hospitals several thousand veterans who have received maximum hospital benefits and are now in need of a form of care which is provided in nursing homes or similar facilities."

Mr. GLEASON. That is right.

Mr. TEAGUE of Texas. Can you keep a veteran like that legally? Mr. GLEASON. Mr. Chairman, there doesn't seem to be much else that we can do with them if there isn't any place for them to go.

Mr. TEAGUE of Texas. That is true, but I didn't ask you that. I asked, legally, can the VA keep a veteran that the doctor says has received maximum hospitalization?

Mr. GLEASON. I am afraid I might have to ask the General Counsel that question, Mr. Chairman.

Mr. TEAGUE of Texas. Let's let him answer it.

Identify yourself, please.

Mr. FABLE. Robert C. Fable, Jr., General Counsel.

There is no question, sir, that title 38 gives complete authority to the Administrator of Veterans' Affairs to give hospitalization or domiciliary care to all veterans who need any type of institutional care. Nursing home care is a phrase that is not known to our law, but the Administrator has the legal authority today to give complete institutional care to all types of veterans regardless of the type of disability which affects them.

Mr. TEAGUE of Texas. Now will you answer the question I asked? Legally can you keep these veterans?

Mr. FABLE. Yes, sir.

To: Administrator (00).

From: General Counsel (02).

Subject: Legal authority to provide nursing home type care.

MAY 7, 1963.

1. You may desire to have for the record a comprehensive opinion setting forth the reasons for the position stated at a recent hearing before the House Committee on Veterans' Affairs, that under the general authorization contained in title 38, United States Code, you have the legal authority to furnish so-called nursing home type attention and care to eligible veterans requiring such care. 2. The terms "nursing home care" and "attendant care" appear to have come into somewhat general usage during the 20th century, particularly in the writings and statements of medical and nursing professionals. These terms are unknown to our veterans' laws and there are no known judicial expressions as the definition of these terms. In fact, there are no consistent medical or nursing views stated as to the precise meaning of these words. Last year, however, the Chief Medical Director advised that a veteran who requires only nursing home type care is not in need of hospitalization.

3. The basic statute (38 U.S.C. 610) authorizes the Administrator to furnish needed hospital care or domiciliary care to veterans who meet the stated eligibility requirements. While "hospital care" is defined (38 U.S.C. 601(5)) to include medical services, the term is not further defined and no definition of "domiciliary care" is set forth in the statutes. Section 4 of Public Law 85-857 which enacted the present title 38, United States Code, preserved in the Administrator the duties, powers, and functions of the National Home for Disabled Volunteer Soldiers which had been vested in him by the Consolidation Act of 1930. The national homes were taken over by the Veterans' Administration pursuant to the 1930 act.

4. We have reviewed much of the historical documentation reflecting the operations of the old National Homes for Disabled Volunteer Soldiers, the predecessor agency, from which was developed the concept of our modern VA domiciliaries. The annual reports of these homes to the Congress contain both statistical and narrative information which, logically construed, clearly reflects the inclusion of members whose needs manifestly were for so-called nursing or attendant care. Based upon the reports of the types and kinds of disease or aflictions at time of entrance and considering the normal effects of advancing age, particularly of the Civil War veteran members, it seems quite clear that veterans were both admitted and retained whose only requirements were for what we now refer to as nursing home care.1 We note the separate classification of aflicted members in so-called convalescent barracks as distinguished from those receiving care in the hospital facility of the home.2 And, we observe, for example, comments such as those in the 1891-92 reports which show that proposals were being advanced to obtain professional nurses to provide personal care and attention theretofore performed by other and presumably more active members. In any event, the early concept and operation of these homes does not appear to have differentiated between degrees, or classification of veterans requiring home care or domiciliation. The basic eligibility was merely service coupled with inability to earn a livelihood with emphasis upon the economic factor.

5. We understand that prior to 1955 some veterans whose primary needs were for attendant type care were admitted to our VA domiciliaries, possibly as an outgrowth of similar admissions of an earlier time to the national homes. In 1955 a determination was made administratively to limit the admission criteria for domiciliary care so that, to be admitted, a veteran must be ambulatory as well as able to feed and clothe himself and perform other self-helps. These requirements were embodied in regulations then promulgated and still in effect. The memorandum to the Administrator of October 5, 1955, explained the proposed change in the regulations and expressed the view that the new limitations on domiciliary care would "*** for the first time give to an examining physician a practical means to establish whether the facilities of domiciliary or the hospital will best serve to meet the requirements of the veteran.' However, it has not been the practice to admit patients to our hospitals whose sole needs are for attendant type or so-called nursing home care. And, of course, the regulations have precluded initial admission to the domiciliaries of attendant type cases since 1955. The

1 Report of the National Soldiers' Home 1891, pp. 69, 170; Report of the Board of Managers of the National Home for Disabled Volunteer Soldiers, 1924 (manuscript).

2 Report of the National Soldiers' Home, 1891-92, pp. 140, 164.

* Id., pp. 85, 185; report for 1892, p. 164.

only current impediment to admitting a veteran who requires only nursing care to a domiciliary is the limitation in the current regulation concerning "self-help" which could be changed.

6. In an opinion to the Chief Medical Director of April 9, 1962, dealing with a somewhat related problem involving recognition of State homes, we stated the view that nursing home type patients receiving only incidental medical treatment could be regarded administratively as receiving a form of domiciliary care. And, in a memorandum opinion to the Assistant Deputy Administrator of April 20, 1962, we held that legal authority exists to provide restorative care under the new restoration center plan now being tried out at VA Center, Hines, Ill. This program also involves patients who are classed as having received maximum hospital benefits and are therefore ready for discharge from purely hospital treatment but who may benefit from intensive rehabilitative forms of treatment, along with some therapeutic measures, as a prelude to attempting their restoration and adjustment to normal community living. We stated that the restorative center plan was supported by law and that it was proper, as planned, to view the patients involved as receiving a form of domiciliary care under the statute. It was suggested that while this care might be classified as hospital care in view of the rather definitive types of treatment involved, the statutory term "domiciliary care" was broad enough to comprehend the services furnished by VA in this experimental program.

7. Inherent in the opinion on restorative care is the premise that the language of the law should be liberally construed to cover various forms of institutional care for our sick and disabled veterans. This takes account of the fact that the dividing line between hospital and domiciliary care is blurred and indistinct as applied to some situations which may partake of both. With due regard for the limitations of facilities and staff, this Office has long recognized that reasonable definitions of "domiciliary care" may be adopted administratively. These definitions may in turn yield to reasonable expansions in accordance with changing circumstances and policies, and need not be confined within static limits.

8. We have considered the memorandum opinions of a former General Counsel to the then Deputy Administrator dated June 24 and July 15, 1959. In those opinions it was concluded that the basic statute did not clearly authorize the furnishing of nursing home care, as such. This was on the theory that such care is distinguishable from "hospital care," and it was also indicated that nursing home cases might not properly be considered for domiciliary care. However, the latter indications were more specifically based on the limiting provisions of the regulations governing domiciliary care. To the extent that there are expressions in those memorandums which appear inconsistent with the views and conclusions stated herein, such expressions are modified to accord with this opinion.

9. We therefore conclude that attendant type of nursing home care may legally be furnished by the Veterans' Administration within the scope of the basic statute authorizing domiciliary care provided the regulations are changed to authorize admission of otherwise eligible veterans requiring such attendant type care. Such a change could, consistent with medical concepts, define and provide for the eligibility in VA facilities of several categories of "domiciliary care," including those who can exercise full self-help, as well as those who, in varying degrees, require partial or full attendant type services.

10. There remains the question of legal authority for retention in our hospitals of patients now requiring only attendant care who were originally admitted for definitive hospital treatment, as well as the retention in our domiciliaries of members admitted under the regulatory criteria who can no longer meet the self-help requirements, where such patients or members have reached the point when a discharge would otherwise be in order, except that a proper place cannot be found at the community level to care for them.

As stated, there is ample statutory authority for attendant type care requiring domiciliation within the overall VĂ system. The regulations which presently bar initial admission to some parts of our institutional system do not require a construction that the patient or member properly admitted thereunder must continuously thereafter satisfy all the admission criteria. This is consistent with past practice and is required to avoid the harsh or even cruel results of summary discharges when no provision can be made for the future care and need of such veterans. The program for a complete medical, hospital, and domiciliary program which the Congress intended must necessarily embrace the authority for retention of such persons until suitable community facilities become available. The fact that a particular veteran may happen to be a patient in a VA hospital or a member of a VA domiciliary beyond the point in question does not change the

situation, nor is it necessary to change his nominal classification as a hospital patient or a domiciliary member simply because he continues to receive during the extended period some form of attendant type domiciliary care. The statute necessarily contemplates that where the Veterans' Administration has properly assumed responsibility for the patient or member in the first instance, its legal and moral responsibility is not fully discharged if the patient is summarily removed as soon as he is medically considered to have received maximum hospital benefits, without completion of some suitable arrangements for any indicated further care. 11. To summarize, it is my firm opinion that the existing law supports the practices of the Veterans' Administration in retaining hospital patients or domiciliary members who have reached the nursing home stage for such time as may be required to make arrangements for their placement in appropriate community facilities. It is my further opinion that there is ample statutory authority for providing attendant type or so-called nursing type care to those admitted initially for that purpose, providing the regulations are changed to authorize admission into the domiciliaries of veterans requiring such care. Whether this should be done is a matter of administrative policy.

Mr. TEAGUE of Texas. Mr. Saylor.

ROBERT C. FABLE, Jr.

Mr. SAYLOR. Mr. Chairman, for the purpose of the record, in view of the fact that the Administrator has stated that his statement has been prepared in response to a letter from the chairman of this committee, I would ask unanimous consent that the letter from the chairman of the Committee on Veterans' Affairs to the Administrator of Veterans' Affairs be placed in the record before the Administrator began to make his statement.

(The letter referred to appears on pages 141–143.)

Mr. TEAGUE of Texas. Without objection, that will be done.

Mr. Adair.

Mr. ADAIR. Mr. Administrator, in these remarks which you have just made, you are contemplating service to both service-connected and non-service-connected veterans?

Mr. GLEASON. As of now, yes, sir; in our study.

Mr. ADAIR. You would make no distinction between them?

Mr. GLEASON. No, sir. Well, we might have two categories for further recommendations at the time we completed the study, Congressman.

Mr. ADAIR. Could you give us an idea of the proportion of serviceconnected to non-service-connected veterans presently hospitalized in the V.A. system?

Mr. GLEASON. About 30 percent would be service-connected, Congressman.

Mr. ADAIR. Do you have any notion then as to whether or not that same figure might apply to nursing homes?

Mr. GLEASON. I would presume that it would apply.

Mr. ADAIR. So we are then thinking in terms of a program which might be directed 30 percent to service-connected and 70 percent to non-service-connected?

Mr. GLEASON. That is correct, sir.

Mr. ADAIR. Do you have any philosophy or does the administration have any philosophy as to the obligation of the Federal Government with respect to nursing home care for non-service-connected veterans?

Mr. GLEASON. Congressman, as I mention in my statement here, this, I believe, is an overall policy that we ourselves must look to. Our primary obligation, of course, is to the service-connected disabled, and whether we get into the nursing home care for the non-service

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