tion 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 or 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 patents 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 VA 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 domicilary 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. ROBERT C. FABLE, Jr. Mr. EVERETT. Mr. Fable, now then it is your thinking and it is your ruling to the Administrator that nursing care can and could be provided in VA without any additional legislation. sir. Mr. FABLE. As a part of our domiciliary program, that is correct, Mr. EVERETT. Then it is also your ruling that we could pay these State homes on a contractural basis for nursing home care, is that so? Mr. FABLE. If the regulations were changed, sir. Mr. EVERETT. The regulations? Will you issue such a new regulation? What is the procedure you go through? Mr. FABLE. The customary procedure in the Veterans Administration is that the organizational element that has the policy responsibility for advising the Administrator would make a study and then they would propose to the Administrator a regulation to achieve the objective they feel is desirable. They would prepare a draft of the change in regulations together with a covering memorandum explaining what it is they seek to achieve. If the Administrator agrees, he approves that. It is published in the Federal Register and it is in effect. Mr. ELLSWORTH. Mr. Chairman, when it is published in the Federal Register there is time given before it goes into effect. In this interim, are not people interested entitled to come to be heard on it? Mr. FABLE. Mr. Ellsworth, this procedure does not apply to the benefits which the Veterans' Administration administers. Mr. ELLSWORTH. The Administrator can change the regulations without subjecting himself to hearings or comment at all? Mr. FABLE. That is correct. Mr. EVERETT. Mr. Roberts. Mr. ROBERTS. Mr. Chairman, I would like to continue on what you were working on here. Would this also extend-would this authority extend to private nursing homes if the Administrator saw fit? That is, would he have legal authority to do this? Mr. FABLE. No, sir. There would only be authority to take care of these veterans in the VA facilities because there is no provision in the statute for domiciliary care to be given in other than VA facilities except under the State home provision that has previously been referred to where there is a partial payment. Mr. EVERETT. Mr. Secrest. Mr. SECREST. No questions. Mr. EVERETT. This 125,000-bed limitation-is it by limitation, not by law, is it, this ceiling that was put on? It was approved by the Budget Bureau and by regulation, right? Mr. FABLE. There is more to it than that. The 125,000-bed ceiling was established by President Eisenhower based on the recommendation of the then Administrator, Mr. Whittier, who wanted to have a firm fix as to what the hospital program would be. I believe that the correspondence relating to that is included in the records of the hospital hearings of a year ago and we would be happy, sir, to insert them again in the record of this hearing if you feel it would serve a purpose. Mr. EVERETT. I would certainly like it to be inserted, and without objection it will be inserted. (The material referred to follows:) The PRESIDENT, The White House, Washington, D.C. FEBRUARY 2, 1959. MY DEAR MR. PRESIDENT: In order to bring up to date the authorized bed capacities of the Veterans' Administration hospitals, it is requested that you approve the attached revised authorization for each of our hospitals. The revised authorizations, which total 125,000 beds for the Veterans' Administration hospital system, are based on the present structural capacity of each of the existing hospitals as modified by previously approved hospital replacement and modernization projects. Also shown are interim authorizations for hospitals affected by approved replacement or modernization projects, to remain in effect until the completion of each project. These revised authorizations, if approved by you, will provide a base for requests for Presidential approval of construction or other acquisition as the need arises. The need for approval of a revised authorization for each hospital is occasioned by many factors. It will bring together for the first time in one document authorizations which have been scattered in many documents since the establishment of the Veterans' Administration. In many cases the number of beds approved when the hospitals were constructed or acquired by the Veterans' Administration are no longer current. As the practice of hospital administration has changed so has the number of beds which can be provided within the hospital's physical plant at accepted bed spacing criteria. Many of the physical facilities acquired from the military services after World War II have been unused for many years and have been demolished or transferred to other organizations or have deteriorated to the point that they could not be used today without the unwise expenditure of thousands of dollars for their rehabilitation. In addition, many of the modernization projects have resulted in the readjustment of beds so that a hospital's bed capacity is no longer as originally approved. In the revised authorizations I am including the use of the 114 additional beds at the Veterans' Administration Hospital at Lake City, Fla. These beds can be provided by the modernization of building No. 38 which we had originally intended to convert for nurses' quarters. The need for this purpose no longer exists and for a small cost these beds can be used for patients to compensate further for the shift of the veteran population to Florida. The proposed revised authorization also includes the Veterans' Administration hospitals at Martinsburg, W. Va., and Vancouver, Wash., both of which were authorized to be acquired from the Army for temporary use pending the development of permanent hospital programs for those areas. The physical condition of these two hospitals is such that they can be continued in operation for the time being without the need for replacement and I, therefore, propose their continued use. It is also requested that you approve the utilization of unused buildings at the Veterans' Administration Hospital, Dublin, Ga., to provide 500 domiciliary beds and a revised authorization of 1,638 domiciliary beds for the Veterans' Administration Center, Dayton, Ohio. The 500 domiciliary beds, when added to the 500 hospital beds authorized for Dublin, Ga., will make full utilization of the hospital's existing structural capacity. It will permit a reduction of 500 domiciliary beds in the 2,138 such beds at the Dayton, Ohio, center and the demolition of 5 obsolete, non-fire-resistant buildings there. I believe that an up-to-date authorized bed capacity for all Veterans' Administration hospitals and the shift in domiciliary beds from Dayton, Ohio, to Dublin, Ga., are urgently required and I recommend your approval. Respectfully, Enclosure. SUMNER G. WHITTIER, Administrator. |