Home of Guiding Hands

National Labor Relations Board - Board Decisions

Jun 30, 1975

218 N.L.R.B. 1278 (N.L.R.B. 1975)

1278 DECISIONS OF NATIONAL LABOR RELATIONS BOARD
Lutheran Association for Retarded Children, A
California Non-Profit Corporation d/b/a Home of
Guiding Hands ' and Office and Professional
Employees International Union , Local 443, AFL,
CIO, Petitioner . Case 21-RC-13969
June 30, 1975
DECISION AND DIRECTION OF
ELECTION
Upon a petition duly filed under Section 9(c) of the
National Labor Relations Act, as amended, a
hearing was held before Hearing Officer Steven J.
Sorensen. Following the hearing and pursuant to
Section 102.67 of the National Labor Relations
Board's Rules and Regulations and Statements of
Procedure, Series 8, as amended, the Regional
Director for Region 21 issued an order transferring
this case to the Board for decision. Thereafter, the
Employer and the Petitioner filed briefs in support of
their respective positions, and briefs amici curiae
were filed by interested parties.
The Board has reviewed the Hearing Officer's
rulings made at the hearing and finds that they are
free from prejudicial error. They are hereby affirmed.
Upon the entire record in this case, the Board
finds:
1. The Employer 2 is a nonprofit California
corporation engaged in providing residential care
and training for mentally retarded children and
adults. The Employer has under its care approxi-
mately 200 resident mentally retarded individuals
who, in terms of their disability, range from the
severely or profoundly retarded to the mildly
retarded. Approximately 4 percent are also deaf and
blind, but the number suffering from other physical
disabilities is not set forth in the record. Some 50
percent of the residents attend classes conducted by
the public schools, while the remaining 50 percent-
not being eligible for public school programs3 -
receive instruction and training in programs conduct-
ed by the Employer.
Residents of the Home are assigned to one of eight
residential cottage units in accordance with the
severity of their disability and the particular type of
training or environment deemed appropriate for
them .4 It appears from the record that the more
i The names of the Employer and the Petitioner appear as amended at
the hearing
2 Also referred to hereinafter as the Home.
3 Their lack of eligibility is due to such factors as being too profoundly
retarded, exhibiting behavior not acceptable in public schools , the presence
of certain physical disabilities , not being toilet trained, or being in an age
group not serviced by public school programs.
4 The populations and characteristics of the cottages are as follows:
Units I and 2 are for mentally retarded adults, Unit 3 is for the severely or
profoundly retarded ; Unit 4 stresses vocational education , Unit 5 applies
behavior modification techniques to young retarded persons, Unit 6 is a
218 NLRB No. 195
capable retarded persons, who reside in Unit 8, are
the only ones whose program is designed with the
ultimate objective of providing training sufficient to
allow them to live in society by themselves.
The Home, situated on a 13.7-acre site in Lakeside,
California, comprises 13 buildings, including the
residential cottages, a health care dispensary, and an
education and training center. It is licensed under
California law as a community care facility.
Limited medical services are provided in the
Home's dispensary where local physicians and
dentists, not on the Employer's staff, examine and
treat the residents. It contains an examining table,
sterilizer, dental chair, and dental x-ray equipment.
In addition, three staff nurses are employed to care
for the health and medication needs of the residents,
with one or more of them being on duty from 8 a.m.
to 10 p.m. on weekdays, and from 8 a.m. to 4:30 p.m.
on weekends.
The Employer's operations are under the direction
and control of the Home's administrator and chief
executive officer who has responsibility for the entire
staff and all programs. The staff under him consists
of 144 employees, including 86 nonsupervisory house
parents, 2 licensed vocational nurses (LVN's), 1
registered nurse (RN),5 a therapist's aide, teachers,
instructors, social workers, clerical employees, and
maintenance employees. In addition, the Home, as
required by California law, has a medical director
who works as an unpaid consultant I day per week, a
physical therapist who works 3 days per week, but is
paid and under the control of an outside agency, and
a consulting psychologist who works 3 hours per
month giving tests and advising on behavioral
problems .6
The Home's employees are distributed among its
various departments which are denominated as
follows: residential care, education and training,
support services, religious, social service, and admin-
istrative. The employees sought in the petition
herein-house parents and nurses-are all employed
within the residential care department.
House parents work on a three-shift basis and are
on duty 24 hours a day, 7 days a week. They are
responsible for, inter alia, physical care of the
residents of their respective units; administering oral
medications pursuant to directions prepared by the
socialization unit for the trainable retarded ; Unit 7 emphasizes the teaching
of toilet training and self-feeding to the young; and Unit 8 provides a sent-
independent environment for the more capable retarded persons.
3 There is an additional RN also employed at the Home, but not
performing nursing duties She is the director of the residential care
department and is a supervisor within the meaning of the Act
a There are also a number of outside consulting doctors , practicing
various medical specialties , who examine and treat residents either at the
Home's dispensary or at their own offices. They are paid for their services
directly by the parents of the residents who receive them.
HOME OF GUIDING HANDS 1279
nurses from the orders of physicians; charting
medications administered; taking record notes on the
health conditions of residents; attending to injured
residents until a nurse arrives; teaching self-help
skills; and maintaining proper nutrition. While they
do not have the authority to directly alter the dosage
of medicines they administer, they can, and do, make
recommendations on these matters to the physicians
on the basis of their personal observation of the
residents. Although they are not required to have had
prior medical experience, it is preferred that they
have experience with the mentally retarded. Once
employed, however, they are given both formal and
informal training in such subjects as retardation
syndrome, causes of mental retardation, home-relat-
ed nursing procedures, behavior modification tech-
niques, teaching self-help skills, nutrition, first aid,
and the significance of the various types of medica-
tion which they may be called on to administer. They
are also issued a 12-page manual covering the
procedures to be used in the administration of
medication and related recordkeeping requirements
and safety precautions.
For the year 1973, the Employer had gross
revenues of $1,300,000 and, on the basis of an
increase in the fees charged for resident care in 1974,
it is estimated that gross revenues for that year were
somewhat higher. Most of this revenue was derived
from monthly fees charged for resident care, said fees
being paid from a variety of sources, including direct
payments by parents or guardians, and payments
from such programs as Social Security Supplementa-
ry Income, Veterans' Administration pensions, Aid
to Dependent Children, and CHAMPUS, an agency
of the Federal Government which pays such fees on
behalf of military dependents.?
In 1967, when the Home was constructed, Federal
Government grants funded one-third of the
$2,200,000 cost. In the past year, the Employer
received direct grants of $50,000 from the U.S.
Department of Health, Education and Welfare for
staffing and curriculum development relating to the
training of retarded children who are also deaf and
blind. As of the date of the hearing, the Employer
intended to apply for the renewal of most, or all, of
such grants for the coming year.
Twenty of the Home's residents come from outside
the State of California and, of those, two had their
tuition paid directly by their State of origin. In all,
fees received on behalf of nonresidents of California
appear to have been in excess of $100,000 per
annum.
Although the Home made no substantial purchases
from outside the State of California, it did purchase
materials and services of an undetermined amount
from the California branches of national corpora-
tions and, as a fund raising device, it sold greeting
cards produced by its residents directly to persons
outside California.
The Employer contends, inter alia, that it is not a
"health care institution" within the meaning of the
new Section 2(14) of the Act8 and that under the
jurisdictional standards and guidelines set forth in
Ming Quong Children's Center, 210 NLRB 899
(1974),9 the Board should decline to assert jurisdic-
tion. For the reasons fully explicated by the Board
majority Beverly Farm Foundation, Incorporated, 218
NLRB 1275 issued this day, we find that
institutions providing care for the mentally retarded,
such as the type of operation maintained by the
Employer herein, clearly fall within the definition of
a health care institution within the meaning of
Section 2(14), and, accordingly, the doctrine of the
Ming Quong case, supra, does not apply.
Inasmuch as the Employer's gross annual income
clearly exceeds the $250,000 jurisdictional standard
which we have established for, inter alia, the type of
health care institution involved herein,10 we find that
the impact of the Employer's operations on com-
merce is sufficient to warrant assertion of jurisdiction
herein and it will effectuate the purposes of the Act
to do so.
2. The parties stipulated and we find that the
Petitioner is a labor organization within the meaning
of the National Labor Relations Act.
3. A question affecting commerce exists concern-
ing the representation of certain employees of the
Employer within the meaning of Sections 9(c)(1) and
2(6) and. (7) of the Act.
4. The Petitioner seeks to represent a unit
consisting of house parents, LVN's, and RN's. The
Employer agrees that such a unit is appropriate, but
would exclude RN's therefrom on the ground that
they are professional employees. Further, the parties
stipulated that the following employee classifications
should be excluded from any unit found appropriate
herein: all other employees, including office and
clerical employees, drivers, maintenance employees,
physical therapists, teaching aides, and supervisors as
defined in the Act. Petitioner concedes the profes-
sional status of RN's and requests that, in accord
7 It appears from the record that CHAMPUS is currently paying all, or he viewed the business aspects of that facility as akin to those of nursing
part, of the fees charged for 25 of the Home 's 200 residents . homes and other related facilities over which the Board has in the past
8 P.L. 93-360 (effective August 25 , 1974) asserted jurisdiction.
9 Member Fanning would have asserted jurisdiction in Ming Quong, a 10 See East Oakland Community Health Alliance, Inc., 218 NLRB 1270
California nonprofit corporation to help emotionally troubled children , as (1975).
1280 DECISIONS OF NATIONAL LABOR RELATIONS BOARD
with the provisions of Section 9(b)(1) of the Act, the
single nonsupervisory RN currently employed by the
Employer be permitted to ballot separately on the
question of her inclusion within a unit of nonprofes-
sional employees, as well as on the question of
whether she desires to be represented by the Union.
The uncontroverted record testimony shows as
follows. The Employer maintains only one classifica-
tion for nurses-"staff nurse"-and the job descrip-
tion for that position requires that employees in the
classification may be either RN's or LVN's. Further,
the actual functions and job duties of the RN and the
LVN's are,identical in every respect, except for the
fact that the RN takes a more formal role in the
teaching of house parents with respect to their
nursing-related duties. Otherwise, all nurses share the
same responsibilities, such as making daily rounds to
check on the health and welfare of residents, being
alert to infectious diseases, maintaining health
records, supervising the administration of oral
medications, and administering injectable medica-
tions and immunizations. The record also shows that
the nurses and house parents work in close coopera-
tion with one another on a daily basis, supplement
one another in the areas of resident health care,
medical recordkeeping, and the administration of
oral medications, and work under the common
supervision of the director of the residential care
department.
In view of the above facts and circumstances, the
stipulations of the parties, and the provisions of
Section 9(b)(1) of the Act, we find as follows. A unit
of all house parents, RN's, and LVN's, excluding all
other employees, office and clerical employees,
drivers, maintenance employees, physical therapists,
teaching aides , and supervisors as defined in the Act,
may constitute a unit appropriate for the purposes of
collective bargaining within the meaning of Section
9(b) of the Act.11 However, as this unit includes
professional and nonprofessional employees, whom
the Board cannot join in a single unit without the
desires of the professional employee being deter-
mined in a separate vote,12 we shall direct that a
separate ballot be used for recording the vote of the
RN, which will ask two questions:
1. Do you wish to be included in the same
unit as the house parents and licensed vocational
nurses employed by the Employer at its Lakeside,
California, facility for the purposes of collective
bargaining?
2. Do you desire to be represented for the
purposes of collective bargaining by Office and
Professional Employees International Union,
Local 443, AFL-CIO?
If the professional employee votes yes to the first
question, indicating her desire to be included in the
unit with the nonprofessional employees, she will be
so included. Her vote on the second question will
then be counted with the votes of the nonprofession-
al employees to decide the representative for that
bargaining unit. If, on the other hand, she does not
vote for inclusion, her vote on the second question
will not be counted, as a one-person unit is not
appropriate.
Accordingly, we find the following unit to be
appropriate for the purposes of collective bargaining
within the meaning of Section 9(b) of the Act:
All house parents, registered nurses,13 and li-
censed vocational nurses employed at the Em-
ployer's Lakeside, California, facility, but exclud-
ing all other employees, office and clerical
employees, drivers, maintenance employees,
physical therapists, teaching aides, and supervi-
sors as defined in the Act.
[Direction of Election omitted from publication.]14
CHAIRMAN MURPHY and MEMBER KENNEDY, dissent-
mg:
The majority has decided to assert jurisdiction over
the Employer on the ground it is a "health care
institution" as defined in recent amendments to the
Act 15 and therefore jurisdiction is mandatory if it
meets certain annual minimum income standards
established by the majority as $250,000. Because we
do not believe that the Employer is a "health care
institution," we would apply the rationale of Ming
Quong Children's Center, 210 NLRB 899 (1974), to
this nonprofit home for retarded children and
dismiss the petition. Accordingly, we dissent.
The Employer is a California nonprofit corporation
operating a residential and educational facility for
mentally retarded children and adults. It is located
on 13.7 acres of land at Lakeside, California, and has
13 buildings, of which 8 are living units housing
mentally retarded residents. It is departmentalized as
follows: residential care, education and training,
support services, religious, social services, and
administrative.
11 In finding that a unit confined to house parents, RN's, and LVN's
may be appropriate herein , we rely in large part on the parties' stipulation
that all other employees should be excluded therefrom. At this time, we
make no determination as to whether we would find such a unit appropriate
absent the stipulation.
12 Sonotone Corporation, 90 NLRB 1236 (1950).
13 If, however, the professional employee does not vote for inclusion in
the unit with nonprofessional employees , we find a unit confined to house
parents and licensed vocational nurses, excluding registered nurses, to be
appropriate herein for purposes of collective bargaining.
14 [Excelsior In. omitted from publication.]
is P.L. 93-360, effective August 25, 1974.
HOME OF GUIDING HANDS 1281
To be admitted to the Home, a person must be at
least 3 years old, be classified as mentally retarded,
and not be an extreme behavioral problem or a
threat to himself or any other person. He cannot
require 24-hour medical care. If, after admission, it
develops that he requires such care, he is transferred
to a facility licensed as a health care facility under
California law; the Employer is licensed only as a
community care facility.
The Home has about 200 residents and 144
employees. Of the latter, the largest number are
house parents.16 In addition, there are two licensed
vocational nurses (LVN's), one therapist's aide, two
registered nurses , teachers, instructors, social work-
ers, various clerical employees, and maintenance
employees.
The Employer does not have a physician on its
staff to provide medical services to the residents nor
does it pay for any physician's services. It does have
a medical director, as required by state law, who acts
as a consultant. However, he receives no pay, does
not perform any medical services for the residents in
his capacity as medical director, and does not
supervise the nurses. If a resident requires a physi-
cian's care, the resident is either seen by a doctor at
the Home or taken to a physician's office. The Home
does not pay for such services and is not involved in
the billing.
The Employer does have a dispensary where local
physicians examine the residents. The dispensary
contains minimal medical equipment, including an
examining table, sterilizer, and a dental chair with
dental x-ray equipment. It does not have an
operating room or medical x-ray equipment.
The Home does not provide 24-hour nursing
service to the residents. There are two registered
nurses and two LVN's. One registered nurse is the
director of residential care and does not function in a
registered nurse's capacity. The other nurse works a
shift of either 8 a.m. to 4:30 p.m. or 10 a.m. to 6 p.m.
The LVN's work in two shifts: one works from 6 a.m.
to 2 p.m., and the other works from 2 p.m. to 10 p.m.
There is a consulting psychologist who works 3
hours a month giving tests and consulting with the
Employer concerning behavioral problems. The
Home also furnishes space to a physical therapist
who is at the Home 3 days a week. He is not an
employee of the Home and is not under its control.
The space is furnished so as to avoid the necessity of
transporting handicapped children to another loca-
16 A house parent must have a high school education and preferably
some experience with retarded persons . He is not required to have any
medical experience . He is involved with the resident 's daily living situation
and teaches self-help skills as well as being responsible for ensuring that the
resident has proper nutrition.
17 Accord. West Oakland Home, Inc., d/b/a Lincoln Child Center, 211
NLRB 755 (1974) (Member Fanning dissenting), Crotched Mountain
tion. The Home does not have an ongoing physical
therapy program.
The Employer's gross income in 1973 was approxi-
mately $1,300,000. Practically all its revenue was
received from sources within the State of California,
It did receive approximately $50,000 from the
Federal Government as a grant for staffing a
program to educate deaf and blind children. All its
purchases are made from businesses within the State.
In Ming Quong Children's Center, supra (Member
Fanning dissenting), the Board decided that it would
not effectuate the policies of the Act to assert
jurisdiction over a nonprofit charitable corporation
which operated a residential facility for the treatment
of emotionally disturbed children.17 The majority
members do not overrule the Ming Quong decision,
but they say it is no longer applicable to a nonprofit
home for the mentally retarded because of the
"health care institution" amendment to the Act.18
Section 2(14) of the Act provides:
The term "health care institution" shall include
any hospital, convalescent hospital, health main-
tenance organization, health clinic, nursing home,
extended care facility, or other institution devoted
to the care of sick, infirm, or aged person.
Apparently, the majority regards a home for the
mentally retarded as included within the clause
"other institution devoted to the care of sick, infirm,
or aged person." As support for this interpretation,
they refer to an explanation offered by Congressman
Thompson during the House debate on the bill.
Congressman Thompson stated that "commercially
operated muscle-building organizations, or those that
provide only health services for weight loss, outside
of any patient care function, would not come within
our definition of health care organization." 19 He
then added:
When we use that term we are looking to real
patient care and health service delivery, whether
inpatient or outpatient. In addition, we do not
mean it just as to the sick or aged. We mean it
also to apply to specialty health services, to private
institutions caring for the mentally retarded and the
like.20 [Emphasis supplied.]
Nowhere else in the legislative history is there any
reference to institutions caring for the mentally
retarded. The majority has construed the under-
Foundation, 212 NLRB 420 ( 1974) (Member Jenkins concurring ; Member
Fanning dissenting); Mission of Our Lady of Mercy, 212 NLRB 855 (1974).
is For a fuller explanation of the majority position see Beverly Farm
Foundation, Incorporated 218 NLRB 1275 (Chairman Murphy and
Member Kennedy dissenting), issued this day.
19 120 Cong Rec 44594 (May 30, 1974).
1o Ibid
1282 DECISIONS OF NATIONAL LABOR RELATIONS BOARD
scored sentence as meaning that Congress intended
specifically to include all kinds of facilities providing
care for the mentally retarded within the definition of
"health care institution ." 21 Fortunately in this case
we have received amicus briefs from several nonprof-
it associations which are concerned with the
problems of the mentally retarded . 22 We also have
the benefit of very perceptive state legislation relating
to the mentally retarded . We believe that both these
sources cast considerable light on what Congressman
Thompson meant by the underscored sentence.
The amici stress that the modern approach to the
mentally retarded is based on the premise that they
are not sick people and do not require "treatment" or
"hospitalization ." Mentally retarded persons are now
regarded as having abilities , talents , needs, and
wishes which differ little in kind from those of most
so-called normal people. Hence, they are now viewed
developmentally , that is, they are capable of growth
and learning regardless of level of retardation or age.
Mental retardation is a broad category. Generally,
it is agreed that a diagnosis of mental retardation is
based on multiple criteria, including measured
intelligence (IQ), adaptive behavior , and medical
classification . The American Association on Mental
Deficiency , an organization of mental retardation
professionals , recognizes four levels of mental retar-
dation based on the degree of deviation from the
average functioning level: mild (IQ 52-67); moderate
(IQ 36-51); severe (IQ 20-35); and profound (IQ 20
or below). Approximately 89 percent of retarded
individuals are mildly retarded , 6 percent are
moderately retarded , and only 5 percent are severely
and profoundly retarded . It is generally accepted that
the mildly retarded are capable of economic self-
sufficiency , and the moderately retarded can be
economically productive in a sheltered employment.
Chapter 2 of the California Health and Safety
Code deals with the licensing of "Health Facilities."
Section 1250 defines a "health facility" as:
[A)ny facility, place or building which is organ-
ized, maintained and operated for the diagnosis,
care and treatment of human illness , physical or
mental , including convalescence and rehabilita-
tion and including care during and after pregnan-
cy, or for any one or more of these purposes for
one or more persons , to which such persons are
admitted for a 24-hour stay or longer, and
includes the following types:
21 See Beverly Farm Foundation, Incorporate4 supra
22 Amicus briefs have been received from, inter alia, the following:
California Association for the Retarded; National Association for Retarded
Citizens; and National Center for Law and the Handicapped, Inc.
23 "In the construction of laws, wills, and other instruments, the 'elusdem
generis rule' is, that where general words follow an enumeration of persons
(a) "General acute care hospital" ... .
(b) "Acute psychiatric hospital" ...
(c) "Skilled nursing facility" ...
(d) "Intermediate care facility" ... .
The California Community Care Facilities Act
enacted in 1973 has a separate licensing provision for
"community care facilities." California Health and
Safety Code Section 1502 defines "community care
facility" as:
[A]ny facility, place or building which is main-
tained and operated to provide non-medical
residential care, day care, or homefrlding agency
services for children and adults, including but not
limited to, the physically handicapped, mentally
impaired, or incompetent persons.
The Employer is licensed by the State of California
as a "community care facility" to "operate and
maintain a Residential Facility-Resident Facility,
Resident School Mentally Retarded" rather than as a
"health facility." There are institutions for dealing
with mentally retarded persons which are licensed as
"health facilities," as opposed to "community care
facilities." Those who are placed in "health facilities"
have mental and physical handicaps of sufficient
severity as to require considerably individualized
assistance in feeding, dressing, and personal hygiene.
With this background, it is helpful to evaluate the
definition of "health care institution" in Section 2(14)
of the Act. The Act specifies as such institutions,
hospitals, convalescent hospitals, health maintenance
organizations, health clinics, nursing homes, and
extended care facilities. The Employer is none of
these. According to the majority, the Employer does
come within the catchall clause "other institution
devoted to the care of sick, infirm, or aged person."
However, as the amici point out, mentally retarded
persons are not, as the result of their condition, "sick,
infirm, or aged." Moreover, under the principle of
ejusdem generis, the concluding clause in Section
2(14) should be construed as applying only to
institutions like those previously enumerated.23
In reaching their determination that the Employer
is a "health care institution" the majority members
lean most heavily upon Congressman Thompson's
remarks during debate referred to above. It should be
noted that in none of the committee reports
discussing the import of the new legislation is there
any reference identical with or similar to those of
or things, by words of a particular and specific meaning , such general words
are not to be construed in their widest extent, but are to be held as applying
only to persons or things of the same general kind or class as those
specifically mentioned." Black's Law Dictionary (Revised Fourth Edition),
p.608.
HOME OF GUIDING HANDS 1283
Representative Thompson. Neither are there any
such references in the Senate debate on the bill. On
the contrary, Senator Williams, sponsor of the
legislation which originated in the Senate, issued the
following words of warning as to the interpretation to
be given to the new legislation. He said: 24
As chairman of the committee and sponsor of
the legislation which originated in the Senate, I
wish to note that this legislation is the product of
intensive efforts over a long period of time by the
Congress and the parties to focus upon adapting
general principles of the Taft-Hartley Act to the
concrete problems that are encountered on a day-
to-day basis in the health care industry. The
Senate Committee strove for a balanced solution,
and the language of its bill and its report and the
explanations thereon by its managers, reflect the
precise results of its studied effort to deal
specifically and in an even handed manner with
these problems. This legislation is the product of
compromise, and the National Labor Relations
Board in administering the act should understand
specifically that this committee understood the issues
confronting it, and went as far as it intended to go
and no further and the Labor Board should use
extreme caution not to read into this act by
implication-or general logical reasoning-some-
thing that is not contained in the bill, its report and
the explanation thereof.
Other statements, of course appear in the record
and form an integral part of the legislative history, in
my judgment, to the extent that the views expressed
by an individual Senator or Congressman accord
with the language of the bill, and the committee
report. [Emphasis supplied.]
The whole burden of the committee reports and the
debates, except for the remarks of Congressman
Thompson, deals with patient care in hospitals, etc.25
Further, Congressman Thompson's remark is itself
ambiguous. He said: "We mean it also to apply to
specialty health services, to private institutions caring
for the mentally retarded, and the like." The
Employer argues, and we believe persuasively, that
the key words in this sentence are "specialty health
services"; that the following reference to institutions
caring for the mentally retarded refers to facilities
which render "specialty health services" to the
mentally retarded, that there are such institutions,
and in California they are licensed as health care
facilities, whereas the Employer is licensed only as a
community care facility.
For the foregoing reasons, we believe that the
majority has misinterpreted Section 2(14) of the Act
so as to include homes for the mentally retarded
within the classification "health care institution."
Inasmuch as we do not regard the Employer as
included within this classification, we would dismiss
the petition.
24 120 Cong. Rec. S12104 (July 10, 1974). under the National Labor Relations Act, 1974 (Senate Committee Print) at
25 See , e g., Legislative History of the Coverage of Nonprofit Hospitals 253, 257, 272, 349, 360, 372, 373