Disaster Preparedness: Limitations in Federal Evacuation
Assistance for Health Facilities Should be Addressed (20-JUL-06,
GAO-06-826).
Hurricane Katrina demonstrated difficulties involved in
evacuating communities and raised questions about how hospitals
and nursing homes plan for evacuations and how the federal
government assists. Due to broad-based congressional interest,
GAO assessed the evacuation of hospital patients and nursing home
residents. Under the Comptroller General's authority to conduct
evaluations on his own initiative, GAO examined (1) the
challenges hospital and nursing home administrators faced, (2)
the extent to which limitations exist in the design of the
National Disaster Medical System (NDMS) to assist with patient
evacuations, and (3) the federal requirements for hospital and
nursing home disaster and evacuation planning. GAO reviewed
documents and interviewed federal officials, and interviewed
hospital and nursing home administrators and state and local
officials in areas affected by Hurricane Katrina in Mississippi
and Hurricane Charley in Florida.
-------------------------Indexing Terms-------------------------
REPORTNUM: GAO-06-826
ACCNO: A57260
TITLE: Disaster Preparedness: Limitations in Federal Evacuation
Assistance for Health Facilities Should be Addressed
DATE: 07/20/2006
SUBJECT: Emergency preparedness
Evacuation
Health care facilities
Hospital administration
Hospitals
Hurricane Katrina
Hurricanes
National disaster medical system
Nursing homes
Evacuation plans
Disaster planning
Natural disasters
National Response Plan
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GAO-06-826
* Results in Brief
* Background
* The National Response Plan
* The National Disaster Medical System
* Regulation of Hospitals and Nursing Homes
* Federal Reports on Health Care Facility Evacuation Due to Hu
* Facility Administrators Faced Several Challenges Related to
* Facility Administrators Faced Challenges in Deciding Whether
* Facility Administrators Had Problems Related to Transportati
* Facility Administrators Faced Communication Challenges Due t
* NDMS Has Two Limitations That Constrain Its Assistance to St
* Federal Requirements for Hospitals and Nursing Homes Include
* Conclusions
* Recommendations for Executive Action
* Agency Comments and Our Evaluation
* GAO Contact
* Acknowledgments
* GAO's Mission
* Obtaining Copies of GAO Reports and Testimony
* Order by Mail or Phone
* To Report Fraud, Waste, and Abuse in Federal Programs
* Congressional Relations
* Public Affairs
Report to Congressional Committees
United States Government Accountability Office
GAO
July 2006
DISASTER PREPAREDNESS
Limitations in Federal Evacuation Assistance for Health Facilities Should
be Addressed
GAO-06-826
Contents
Letter 1
Results in Brief 4
Background 6
Facility Administrators Faced Several Challenges Related to Evacuation,
Including Deciding Whether to Evacuate, Securing Transportation, and
Maintaining Communication 11
NDMS Has Two Limitations That Constrain Its Assistance to State and Local
Governments with Patient Evacuation and Which Are Not Addressed Elsewhere
in the NRP 15
Federal Requirements for Hospitals and Nursing Homes Include Provisions
for Having Disaster Plans and Transferring Patients Out of Hospitals 17
Conclusions 18
Recommendations for Executive Action 19
Agency Comments and Our Evaluation 20
Appendix I Scope and Methodology 24
Appendix II CMS Regulations and Interpretive Guidelines Related to
Hospital and Nursing Home Disaster and Evacuation 27
Appendix III JCAHO and AOA Requirements for Hospital Evacuation Planning
and Emergency Preparedness 30
Appendix IV Comments from the Department of Homeland Security 44
Appendix V Comments from the Department of Defense 46
Appendix VI Comments from the Department of Health and Human Services 48
Appendix VII Comments from the Department of Veterans Affairs 49
Appendix VIII GAO Contact and Staff Acknowledgments 50
Related GAO Products 51
Tables
Table 1: CMS Regulation and Interpretive Guidelines for Hospitals 27
Table 2: CMS Guidance to Surveyors for Long Term Care Facilities 29
Table 3: 2005 AOA Accreditation Requirements for Hospitals 41
Abbreviations
AOA American Osteopathic Association CMS Centers for Medicare & Medicaid
Services DHS Department of Homeland Security DMAT Disaster Medical
Assistance Team DOD Department of Defense DOT Department of Transportation
EOC emergency operations center ESF emergency support function FEMA
Federal Emergency Management Agency HHS Department of Health and Human
Services JCAHO Joint Commission on Accreditation of Healthcare
Organizations NDMS National Disaster Medical System NRP National Response
Plan QAPI quality assessment performance improvement VA Department of
Veterans Affairs
This is a work of the U.S. government and is not subject to copyright
protection in the United States. It may be reproduced and distributed in
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copyright holder may be necessary if you wish to reproduce this material
separately.
United States Government Accountability Office
Washington, DC 20548
July 20, 2006
Congressional Committees
On August 29, 2005, Hurricane Katrina struck near the
Louisiana-Mississippi border and became one of the worst natural disasters
in U.S. history. Hurricane Katrina affected a large geographic area and
necessitated the evacuation of parts of the area. Among those needing to
be evacuated were people in health care facilities such as hospitals and
nursing homes. During disasters such as Hurricane Katrina, administrators
of hospitals or nursing homes must make decisions about the best way to
care for their patients or residents under such circumstances, including
whether to evacuate if the facility becomes unable to support adequate
care, treatment, or other services.1 Moreover, if administrators decide to
evacuate, hospital patients or nursing home residents may need special
equipment or have other complicating factors which inhibit their movement,
thereby increasing the risk to their safety during the evacuation process.
Due to Hurricane Katrina, efforts were made to evacuate hospital patients
and nursing home residents. In the storm's aftermath, congressional
reports raised questions about how health care facility administrators
plan for hurricanes, how they implement their plans, and how the federal
government assists health care facilities and state and local governments
with facility evacuations.2
Federal, state, and local governments, as well as individual health care
facilities, have plans for how they will respond to emergencies such as
hurricanes. At the federal level, the National Response Plan (NRP)3
provides a framework for how the federal government is to assist states
and localities in managing domestic incidents, including both incidents of
national significance and those of lesser severity.4 A program identified
in the NRP, the National Disaster Medical System (NDMS), can assist state
and local governments with evacuations of patients who need hospital
care.5 NDMS is a partnership of four federal agencies, and the Department
of Homeland Security (DHS) is the lead agency.6 At the state and local
levels, governments often have comprehensive emergency management plans
that mirror the NRP. At the individual facility level, hospitals and
nursing homes that participate in the Medicare and Medicaid programs must
comply with requirements established by the Department of Health and Human
Services' (HHS) Centers for Medicare & Medicaid Services (CMS).7
Compliance with these requirements is assessed by accrediting
organizations such as the Joint Commission on Accreditation of Healthcare
Organizations (JCAHO) and the American Osteopathic Association (AOA), and
state agencies.
1For our purposes, evacuation refers to moving all hospital patients or
nursing home residents out of both the facility and the affected area.
2See U.S. House of Representatives, A Failure of Initiative: Final Report
of the Select Bipartisan Committee to Investigate the Preparation for and
Response to Hurricane Katrina (Feb. 15, 2006). See also Committee on
Homeland Security and Governmental Affairs, U.S. Senate, Hurricane
Katrina: A Nation Still Unprepared (May 2006).
3This report reflects the NRP as updated on May 25, 2006.
Due to broad-based congressional interest, we assessed the evacuation of
hospital patients and nursing home residents due to hurricanes. We
performed this work under the Comptroller General's authority to conduct
evaluations on his own initiative.8 In February 2006, we reported on
preliminary observations from our work,9 and in May 2006, we testified on
our preliminary observations before the Senate Special Committee on
Aging.10 To complete our assessment, we examined (1) the challenges
hospital and nursing home administrators faced related to recent
hurricanes, (2) the extent to which limitations exist in the design of
NDMS or other federal programs to assist state and local governments with
patient evacuations, and (3) the federal requirements for hospital and
nursing home disaster and evacuation planning.
4Under the NRP, the Secretary of Homeland Security will consider, but is
not limited to, the four criteria stated in Homeland Security Presidential
Directive 5 (HSPD-5) when deciding whether to declare an incident of
national significance. These criteria are: (1) a federal department or
agency acting under its own authority has requested the assistance of the
Secretary of Homeland Security, (2) the resources of state and local
authorities are overwhelmed and federal assistance has been requested by
the appropriate state and local authorities, (3) more than one federal
department or agency has become substantially involved in responding to an
incident, or (4) the Secretary of Homeland Security has been directed to
assume responsibility for managing a domestic incident by the President.
5Public Health Security and Bioterrorism Preparedness and Response Act of
2002, Pub. L. No. 107-188, S: 102(a), 116 Stat. 595, 599 (formally
establishing a program otherwise in operation since 1984; to be codified
at 42 U.S.C. S: 300hh-11).
6The NDMS partners are DHS, Department of Health and Human Services (HHS),
Department of Veterans Affairs (VA), and Department of Defense (DOD). The
Homeland Security Act of 2002 transferred overall NDMS responsibility to
DHS from HHS. Pub. L. No. 107-296, S: 503(5), 116 Stat. 2135, 2213
(codified at 6 U.S.C. S: 313(5)). H.R. 5438, 109th Cong. (2006), which was
introduced May 22, 2006, would transfer overall NDMS responsibility back
to HHS.
7CMS issues interpretive guidelines that contain authoritative
interpretations and clarifications of statutory and regulatory provisions,
and these are to be used to make compliance determinations. Throughout
this report, we refer to both CMS regulations and interpretive guidelines
as "requirements."
831 U.S.C. S: 717(b)(1) (2000).
For our first objective related to the challenges hospital and nursing
home administrators faced related to recent hurricanes, we reviewed
documents, including emergency management plans from state and local
governments and hospitals and nursing homes in Florida and Mississippi. We
interviewed officials in Mississippi who experienced Hurricane Katrina,
including officials from five hospitals, three nursing homes and assisted
living facilities, state officials, and local emergency management
officials in two counties. We also interviewed officials in Florida in
areas that experienced hurricanes in 2004, particularly those affected by
Hurricane Charley, which was the strongest hurricane to hit the United
States since Andrew hit southern Florida in 1992.11 In Florida, we spoke
with officials from three hospitals and three nursing homes, state
officials, and local emergency management officials in two counties. We
also interviewed officials from national hospital and nursing home
associations, Florida hospital and nursing home associations, and a
Mississippi nursing home association. For our second objective concerning
the extent to which limitations exist in the ability of NDMS or other
federal programs to assist state and local governments with patient
evacuations, we reviewed federal documents such as the NRP, including the
September 2005 draft Catastrophic Incident Supplement to the NRP. We also
interviewed officials from the Department of Defense (DOD), HHS, DHS, the
Department of Transportation (DOT), and the Department of Veterans Affairs
(VA), including officials who are responsible for NDMS, asking about
moving patients out of facilities and out of the affected areas. For our
third objective on federal requirements for hospital and nursing home
disaster and evacuation planning, we reviewed CMS documents describing
hospital and nursing home emergency planning requirements that
specifically relate to evacuations. We also interviewed officials from
CMS, JCAHO, and AOA concerning these requirements, as well as officials
from national hospital and nursing home associations, Florida hospital and
nursing home associations, and a Mississippi nursing home association. In
addition, we interviewed officials and obtained documents from the Florida
Agency for Healthcare Administration and Mississippi Department of Health
concerning state hospital and nursing home requirements for evacuation.
For additional information on our scope and methodology, see appendix I.
Our work was performed from October 2005 through July 2006 in accordance
with generally accepted government auditing standards.
9GAO, Disaster Preparedness: Preliminary Observations on the Evacuation of
Hospitals and Nursing Homes Due to Hurricanes, GAO-06-443R (Washington,
D.C.: Feb. 16, 2006). Also see related GAO products at the end of this
report.
10GAO, Disaster Preparedness: Preliminary Observations on the Evacuation
of Vulnerable Populations due to Hurricanes and Other Disasters,
GAO-06-790T (Washington, D.C.: May 18, 2006).
11Hurricane Charley struck the Gulf Coast of Florida on August 13, 2004.
The hurricane continued across Florida to exit the state on the Atlantic
Coast on August 14, 2004.
Results in Brief
Hospital and nursing home administrators faced several challenges related
to evacuations during recent hurricanes, including deciding whether to
evacuate or stay in their facilities and "shelter in place", obtaining
transportation necessary for evacuations, and maintaining communication
outside of their facilities. Administrators said they generally prefer to
shelter in place, but when doing so they must have sufficient resources to
provide care during a hurricane, and maintain self-sufficiency immediately
after a hurricane to continue to care for patients until help can arrive.
For example, during hurricanes Katrina and Charley, administrators had to
ensure that their facilities had needed resources, including staff who
could stay at the facility for 3 or more days; sufficient food, water, and
supplies to account for the inability to replenish resources during the
hurricane; and power, which required having enough fuel to run generators
for multiple days. When evacuations were needed, facility administrators
said that they had problems with transportation, such as securing the
vehicles needed to evacuate patients. Although facilities had contracts
with transportation companies, competition for the same pool of vehicles
created supply shortages. In addition, communication was impaired by
hurricane damage to the local infrastructure. For example, a nursing home
in Florida was unable to communicate with local emergency managers.
NDMS has two limitations in its design that constrain its assistance to
state and local governments with patient evacuation, and which are not
addressed elsewhere in the NRP. The first limitation is that NDMS
evacuation efforts begin at a mobilization center, such as an airport, and
do not include short-distance transportation assets, such as ambulances or
helicopters, to move patients out of health care facilities to
mobilization centers. Moreover, based on the documents we reviewed,
including the NRP, we found that there are no other federal programs that
assist with this transportation function. The second limitation is that
NDMS supports the evacuation of patients needing hospital care; the
program was not designed nor is it currently configured to move people who
do not require hospitalization, such as nursing home residents. Although
NDMS moved nursing home residents during Hurricane Katrina who were
brought to mobilization centers, NDMS officials had to make special
arrangements for people in need of nursing home care because NDMS lacked
preexisting agreements with nursing homes. The movement of nursing home
residents during evacuations is not addressed elsewhere in the NRP.
At the federal level, CMS has requirements related to hospital and nursing
home disaster and evacuation planning as a condition of participation in
the Medicare and Medicaid programs. For hospitals, CMS requires that the
overall hospital environment must be maintained to assure the safety and
well-being of patients. According to CMS guidelines for interpreting this
regulation, hospitals must develop and maintain comprehensive emergency
plans, and when developing plans, should consider the transfer of patients
to other health care settings or hospitals if necessary. For nursing
homes, CMS requires that facilities must have plans to meet all potential
emergencies and disasters, although CMS guidelines for interpreting the
regulation do not specifically mention transfer of residents. In addition,
JCAHO, AOA, and states can also have additional emergency management
requirements. For example, JCAHO requires that hospitals it accredits have
emergency plans that include provisions for evacuating the entire building
and transporting patients, supplies, staff, and equipment to alternate
care sites if necessary.
We are recommending that DHS clearly delineate how the federal government
will assist state and local governments with the transportation of
patients and residents out of hospitals and nursing homes to a
mobilization center where NDMS evacuation begins. We further recommend
that DHS, in consultation with the three other NDMS partners, clearly
delineate how to address the needs of nursing home residents during
evacuations, including the arrangements necessary to relocate these
residents.
We received written comments on a draft of this report from DHS, DOD, HHS,
and VA. DHS stated that it will take our recommendations under advisement
as it reviews the National Response Plan. According to DHS, all of the
NDMS federal partners are currently reviewing the NDMS memorandum of
agreement with a view toward working with state and local partners to
alter, delineate, and otherwise clarify roles and responsibilities as
appropriate. HHS and VA generally agreed with our recommendations. DOD
disagreed with our conclusion regarding NDMS limitations, noting that
state and local governments are responsible for the provision of
short-distance transportation, rather than it being a federal
responsibility. However, DHS confirmed that while the primary
responsibility for evacuations remains with state and local governments,
the federal government becomes involved when the capabilities of the state
and local governments are overwhelmed, as we reported. We therefore
believe that it is important for DHS to clearly delineate how the federal
government will assist state and local governments in these instances.
Background
At the federal level, the NRP provides a framework for how the federal
government is to assist states and localities in managing emergencies and
major disasters. NDMS is one of the programs identified in the NRP that
can supplement state and local medical resources during emergencies,
including providing resources to assist with evacuation. At the individual
facility level, hospitals and nursing homes must comply with CMS
requirements to participate in the Medicare and Medicaid programs. Several
recently issued federal reports have looked at the adequacy of health care
facility disaster planning, as prompted by Hurricane Katrina.
The National Response Plan
In December 2004, DHS issued the NRP to consolidate existing federal
government emergency response plans into a single coordinated plan, as
mandated by the Homeland Security Act of 2002.12 The NRP provides a
framework for how the federal government is to assist states and
localities in managing domestic incidents, including an "emergency"13 or a
"major disaster"14 declared by the President under the Robert T. Stafford
Disaster Relief and Emergency Assistance Act (Stafford Act).15 On May 25,
2006, DHS revised the NRP to address certain weaknesses or ambiguities
identified following Hurricane Katrina.16
12Pub. L. No. 107-296, S: 502(6), 116 Stat. 2135, 2212-13 (to be codified
at 6 U.S.C. S: 312(6)). The NRP supersedes other federal emergency
planning documents, including the Initial National Response Plan and the
Federal Response Plan.
13An emergency is defined as any occasion or instance for which, in the
determination of the President, federal assistance is needed to supplement
state and local efforts and capabilities to save lives and to protect
property and public health and safety, or to lessen or avert the threat of
a catastrophe in any part of the United States. 42 U.S.C. S: 5122(1)
(2000).
The NRP includes a Catastrophic Incident Annex, which provides for an
accelerated, proactive national response to catastrophic incidents-defined
as any natural or manmade incident, including terrorism, resulting in
extraordinary levels of mass casualties, damage, or disruption severely
affecting the population, infrastructure, environment, economy, national
morale, and/or government functions.17 By definition, a catastrophic
incident almost immediately exceeds resources normally available to state,
local, tribal, and private-sector authorities in the impacted area. A
separate Catastrophic Incident Supplement, which was drafted but had not
been approved at the time of Hurricane Katrina, provides additional detail
on the roles and responsibilities of federal, state, and local responders
during catastrophic incidents. However, as of June 2006, the supplement
had not been finalized.
Among its many components, the NRP establishes 15 emergency support
functions (ESF), which identify resources and define the missions and
responsibilities of various federal agencies in helping coordinate support
during incidents of national significance. For each of the NRP's 15 ESFs,
which include Transportation, Communications, Firefighting, and Public
Health and Medical Services, the NRP designates a federal agency as the
ESF coordinator responsible for pre-incident planning and coordination. It
also designates one or more primary agencies to be responsible for
operational priorities and activities, coordinating with other agencies
and state partners, and planning for incident management. HHS, for
example, is designated as the ESF coordinator and the primary agency for
ESF #8-Public Health and Medical Services.
14Major disaster is defined as any natural catastrophe or, regardless of
cause, any fire, flood, or explosion, in any part of the United States,
which in the determination of the President causes damage of sufficient
severity and magnitude to warrant major disaster assistance under the
Stafford Act to supplement the efforts and available resources of states,
local governments, and disaster relief organizations in alleviating
damage, loss, hardship, or suffering. 42 U.S.C. S: 5122(2) (2000).
15Pub. L. No. 93-288, 88 Stat. 143 (1974) (codified as amended at 42
U.S.C. S:S: 5121-5206). The Stafford Act primarily establishes the
programs and processes the federal government uses to provide emergency
and major disaster assistance to states, local governments, tribal
nations, individuals, and qualified private nonprofit organizations.
16The revised NRP makes clear that the Secretary of Homeland Security is
responsible for declaring and managing incidents of national significance
such as Hurricane Katrina. Incidents of lesser severity requiring federal
involvement are also subject to the NRP, but implementation of the NRP is
to be scaled and flexible depending on the nature of the event.
17The responsibility for determining whether an incident of national
significance meets the NRP's definition of a "catastrophic incident" rests
with the Secretary of Homeland Security. The Secretary makes a
"catastrophic incident" designation to activate the provisions of the
annex. The Secretary declared Hurricane Katrina an incident of national
significance on August 30, 2005, but never declared it a catastrophic
incident. The revised NRP makes explicit that the Secretary could activate
the annex to address events that are projected to mature to catastrophic
proportions, such as strengthening hurricanes.
The National Disaster Medical System
NDMS, one of the programs included in ESF #8-Public Health and Medical
Services-of the NRP, was formed in 1984 to care for massive numbers of
casualties generated in a domestic disaster or an overseas conventional
war. It is a nationwide medical response system to supplement state and
local medical resources during disasters and emergencies and to provide
back-up medical support to the military and VA health care systems during
an overseas conventional conflict. DOD, HHS, DHS, and VA are federal
partners in NDMS. These partners most recently signed a memorandum of
agreement in October 2005 that describes the roles and responsibilities of
each partner. DHS has the authority to activate NDMS in response to public
health emergencies, which include, but are not limited to, presidentially
declared emergencies or major disasters under the Stafford Act.
NDMS consists of three key functions:
o medical response, which includes medical equipment and
supplies, patient triage, and other emergency health care services
provided to disaster victims at a disaster site through NDMS
medical response teams such as Disaster Medical Assistance Teams
(DMAT);18
o patient evacuation, which includes communication and
transportation to evacuate patients from a mobilization center
near the disaster site, such as an airport, to reception
facilities in other locations; and
o "definitive care," which is additional medical care-beyond
emergency care-that begins once disaster victims are placed into
an NDMS inpatient treatment facility (typically a nonfederal
hospital that has signed an agreement with NDMS).
DHS has lead responsibility for the medical response function of
NDMS. DOD takes the lead in coordinating patient evacuation for
NDMS, in collaboration with DOT, the other NDMS federal partners,
and commercial transportation companies. VA and DOD share lead
responsibility for arranging definitive care, including tracking
the availability of beds in hospitals that participate in NDMS.19
NDMS was used to supplement state and local patient evacuation
efforts during Hurricane Katrina and Hurricane Rita, which struck
the Gulf Coast several weeks after Hurricane Katrina. NDMS
officials told us that Hurricane Katrina was the first time that
the patient evacuation and definitive care components of NDMS were
used for a large number of patients. In response to state requests
for assistance, NDMS moved people from Louisiana after Hurricane
Katrina and from Texas before Hurricane Rita. In total, about
2,900 people were transported to NDMS patient reception areas due
to the two hurricanes.
CMS establishes federal regulations that hospitals and nursing
homes must meet to participate in the Medicare and Medicaid
programs.20 These regulations relate to many aspects of hospital
or nursing home operations, such as health care services, dietetic
services, and physical environment, including emergency
management. Hospitals that are accredited by JCAHO or AOA are
generally deemed to meet most of these Medicare and Medicaid
requirements;21 no organizations have similar deeming authority
for nursing homes.22 State agencies survey and certify nursing
homes and nonaccredited hospitals to ensure that they follow CMS
requirements. CMS provides guidance to state agencies in the CMS
State Operations Manual, which includes interpretive guidelines
and survey procedures for state agencies to assess compliance with
CMS regulations.23 In addition to CMS requirements, JCAHO, AOA,
and states can establish additional requirements for hospitals and
nursing homes.
A number of federal reports address the issue of evacuation and
health care facility disaster planning. These reports have in
various ways called for improvements in coordination. The White
House report on lessons learned from the federal response to
Hurricane Katrina recommended that agencies coordinate together to
plan, train, and conduct exercises to evacuate patients when state
and local agencies are unable to do so in a timely or effective
manner.24 The House of Representatives Select Bipartisan Committee
to Investigate the Preparation for and Response to Hurricane
Katrina reported that medical care and evacuations suffered from a
lack of advance preparations, inadequate communications, and
difficulties in coordinating efforts.25 The select committee's
report and a DHS Office of Inspector General Performance Review of
the Federal Emergency Management Agency (FEMA) both noted that
search and rescue efforts during Hurricane Katrina were effective
but could have benefited from improved coordination among federal
agencies.26 The Senate Committee on Homeland Security and
Governmental Affairs reported that federal agencies involved in
providing medical assistance did not have adequate resources or
the right medical capabilities to fully meet the medical needs
arising from Katrina, such as meeting the needs of large evacuee
populations, and were forced to use improvised and unproven
techniques to meet those needs.27 Further, the committee reported
that the federal government's medical response suffered from a
lack of planning, coordination, and cooperation.
Hospital and nursing home administrators faced several challenges
related to evacuation during recent hurricanes, including deciding
whether to evacuate or stay in their facilities and "shelter in
place", obtaining transportation necessary for evacuations, and
maintaining communication outside of their facilities.
Administrators said they generally prefer to shelter in place, and
when doing so must have the resources needed to provide care
during a hurricane, and maintain self-sufficiency immediately
after a hurricane to continue to care for patients until help can
arrive. When evacuations were needed, facility administrators said
that they had problems with transportation. Facilities had
contracts with transportation companies, but competition for the
same pool of vehicles created supply shortages. In addition,
communication was impaired by damage to local infrastructure as a
result of the hurricanes. For example, a nursing home in Florida
was unable to communicate with local emergency managers.
Hospital and nursing home administrators told us that they faced
challenges in deciding whether to evacuate, including ensuring
that they had sufficient resources to provide care or other
services during the disaster and then in its aftermath until
assistance could arrive. Administrators told us that they evacuate
only as a last resort and that facilities' emergency plans are
designed primarily to shelter in place. Some hospitals provided a
safe haven for devastated communities after a hurricane. In
addition, some hospitals saw a surge in the number of people
seeking care as a result of injuries sustained during the
hurricane. For example, clinicians at a 153-bed hospital in
Mississippi treated approximately 500 patients per day in the days
after Hurricane Katrina, a substantial increase from their normal
workload of about 130 patients per day. This hospital's
administrators told us that they felt obligated to remain open to
serve the community's needs. In addition, facility administrators
and county representatives that we interviewed agreed that
sheltering in place is generally safer than evacuating vulnerable
hospital patients and nursing home residents. Although state and
local governments can issue mandatory evacuation orders for
certain areas, health care facilities may be exempt from these
orders, as they were in a Mississippi county for Hurricane
Katrina. When preparing to shelter in place, hospital
administrators told us that they discharge patients when possible
and stop performing elective surgeries to reduce the number of
patients in the hospital.
In anticipation of an inability to replenish resources during a
hurricane, hospital and nursing home administrators take steps
before hurricanes to ensure that the facilities have the resources
needed to shelter in place and adequately care for patients and
residents, including sufficient supplies, food, water, and power.
For example, a nursing home administrator in Florida told us that
the facility prepared for Hurricane Charley by obtaining 10 days
of food and water for its 120 residents plus additional Meals,
Ready-to-Eat28 to feed 500 people for up to 4 days, including
staff and their families. Administrators from a hospital told us
that they call their vendors 72 hours before a hurricane to order
bulk supplies of milk, bread, and paper goods. Administrators from
a Mississippi hospital noted that they prepare for hurricanes by
ensuring that the facility has 3-4 days of clean linens and 5-6
days of medical supplies. Administrators must also make sure they
have sufficient backup electrical power because life support
systems require electricity to operate. One hospital administrator
acquired an additional generator to extend the hospital's capacity
to supply backup power to 10 days. In addition, many of the
administrators we interviewed noted that they maintain large fuel
tanks to power the generators. For example, one hospital
maintained a 20,000 gallon tank, which holds enough fuel to run
the facility's generators for 1 week. Some administrators told us
that they also had difficulty obtaining sufficient fuel after the
hurricanes.
In addition to obtaining tangible supplies, administrators face
the challenge of ensuring that facilities have the staff needed to
provide adequate patient care during and after a hurricane.
Hospital administrators noted the challenges involved with having
sufficient numbers of clinical staff, such as doctors, available
during hurricanes. Some facility administrators we interviewed
identified "storm teams" of staff that were required to report to
the facility before a hurricane and remain on site during the
event. One hospital required the "storm team" to be prepared to
stay at the facility for 3-4 days. Staff members were required to
bring clothes, bedding, snacks, and other personal items. In some
cases, facilities also allowed these staff members to bring their
families and pets. One hospital administrator in Mississippi noted
that the severity and destruction caused by Hurricane Katrina
prevented the relief staff from taking over and the "storm team"
remained at the facility for 14 days. Another hospital
administrator in Florida noted that after Hurricane Charley,
relief staff did not report for work.
Hospital and nursing home administrators we interviewed reported
that their facilities needed to be self-sufficient for a period of
time immediately after a hurricane because new supplies may not
arrive for several days. For example, a representative of a
Florida nursing home association said that facilities need at
least 10 days of supplies to effectively shelter in place until
help can arrive. The need to be self-sufficient is especially
important when disasters affect entire communities and delay
response efforts, as demonstrated during hurricanes Charley and
Katrina. Facilities that were part of networks were able to call
on their corporate offices or sister facilities outside of the
affected area to replenish needed supplies after a hurricane. For
example, one administrator said that the company that owns his
hospital has a division that tracks each facility's preparedness
resources, and the company's supply warehouse has "disaster packs"
of necessary supplies ready to be deployed in case of emergency.
Additionally, the company has large contracts in place so that it
can quickly obtain resources like fuel, generators, and staff.
Facility administrators noted that they were not always able to
obtain appropriate vehicles to accommodate their facilities'
patient needs. While some people can be moved using buses, some
may require wheelchair-accessible vehicles, and others may need to
be transported by ambulance. For example, one nursing home
administrator noted that the facility contracted with a bus
company, but stated that transportation remained a challenge
because most of the facility's residents used electric wheelchairs
and needed vehicles with power lifts, which were not available. In
addition, facilities also needed trucks to move staff and supplies
to care for the patients. For example, one Florida nursing home
administrator noted that the facility had arrangements with a
trucking company to load and transport patient medical records,
medications, laundry supplies, food, and water. Another nursing
home administrator in Mississippi said that he rented a truck to
move mattresses and other supplies for his residents.
Having a contract with a transportation company or relying on the
local government did not guarantee availability of transportation
resources during a hurricane. Although facility administrators
reported having contracts with transportation companies,
competition for the same pool of vehicles created supply
shortages. Hospital and nursing home administrators in several
communities told us that their transportation companies also had
contracts with other facilities in the community to provide
services, a situation that may be sufficient for small evacuations
but did not work when there were multiple facilities from the same
area that needed to evacuate. In addition to contracting with
multiple facilities, some companies' vehicles were unavailable due
to advance notice requirements, and others may have had vehicles
that were badly damaged by the hurricane. For example, one nursing
home administrator said that the bus company his facility
contracted with required 24-hours notice before a bus could be
chartered, and that providing this notice was difficult in a
disaster situation. Some facilities relied upon local government
resources to provide assistance with evacuations, but when an
entire community was severely affected, local ambulances were
damaged or in short supply and therefore unavailable. For example,
one Florida hospital administrator had arranged for transportation
through the local emergency operations center (EOC), but the
hurricane destroyed the EOC. In contrast, when local officials in
Mississippi faced a shortage of ambulances immediately after
Hurricane Katrina, they called upon a national ambulance company,
with which they had a contract, to provide additional resources
from Texas and Alabama. Officials noted that state resources were
not available after the storm and contracting with an ambulance
company with national resources was beneficial.
Hurricanes Charley and Katrina caused significant damage to the
infrastructure of the surrounding communities, and left some
hospital and nursing home administrators unable to communicate
outside of their facilities. Several administrators that we
interviewed reported that land-based telephone lines were not
functional and cellular telephone reception was sporadic. Some
administrators reported that cell phones based in other areas were
more reliable than local cell phones. Since the 2004 hurricane
season, some facilities in Florida have purchased satellite
phones. For example, one nursing home administrator who faced
communications difficulties after Hurricane Charley has since
purchased satellite phones. However, during Hurricane Katrina,
some Mississippi hospital administrators told us that their
satellite phones did not function. Because no single
communications technology is universally reliable, some facility
administrators told us that they plan to diversify their
communication capabilities by utilizing multiple forms of
communication.
Communication problems also affected county officials. Local EOC
officials in both Mississippi and Florida reported being unable to
communicate with state officials or local health care facilities.
Because of communication problems at the local EOC, one nursing
home administrator in Florida asked a staff member to drive to the
EOC to communicate in person. In Mississippi, emergency managers
relied on handheld radios and personal contact to communicate
immediately after the hurricane. We have previously reported on
communication difficulties during a public health emergency.29
NDMS has two limitations in its design that constrain its
assistance to state and local governments with patient evacuation.
First, NDMS is not designed to move patients or residents out of
hospitals or nursing homes to mobilization centers. Second, NDMS
was not designed nor is it currently configured for people who do
not need hospital care, including nursing home residents.
The first limitation of NDMS is that it is designed to move
patients from a mobilization center, such as an airport, to other
locations where they can receive necessary medical care, but it is
not designed to move patients or residents out of hospitals or
nursing homes to mobilization centers. NDMS officials told us that
transportation from a health care facility to an NDMS mobilization
center is the responsibility of local and state governments.
Moreover, NDMS does not include helicopters, ambulances, or other
short-distance vehicles necessary to move patients out of
hospitals or nursing homes to mobilization centers. NDMS officials
stated that NDMS transportation assets typically are large DOD
airplanes designed to travel long distances, which can take
approximately 24 hours or more to arrange. In addition, NDMS
officials told us that to obtain ambulance or helicopter service,
they would contract with private providers near a disaster site,
which could lead to competition between the federal government and
state and local authorities for the same pool of limited
resources.30
Although NDMS evacuation efforts begin at mobilization centers,
federal officials told us that no federal program is designed to
move patients or residents out of hospitals or nursing homes to
mobilization centers. NDMS and other documents that we reviewed
also do not identify other federal programs that might assist in
performing this function. We reviewed the NRP, the September 2005
draft Catastrophic Incident Supplement to the NRP, and NDMS
documents. They do not indicate how the federal government is to
assist state and local authorities in moving hospital patients and
nursing home residents from their facilities. In particular, the
September 2005 draft Catastrophic Incident Supplement to the NRP,
which is intended to be used with the Catastrophic Incident Annex
when a catastrophic incident almost immediately overwhelms the
capabilities of state and local governments, states that
collecting and transporting patients from health care facilities
to mobilization centers is the responsibility of state and local
authorities. The draft supplement does not describe what, if any,
role the federal government may play in coordinating with state
and local authorities for this kind of transportation.
Despite this limitation of NDMS, some federal assistance was
provided to move people out of health care facilities during
Hurricane Katrina. Coast Guard officials told us that they
evacuated about 9,400 people from hospitals and nursing homes as
part of their search and rescue operations. NDMS officials
reported that private, local, state, and federal resources
transported hospital patients and nursing home residents to
mobilization points, but there was a lack of coordination. For
example, a report prepared by NDMS officials after Hurricane
Katrina noted that, initially, transportation resources from the
Coast Guard and DOD were not coordinated.31
The second limitation is that NDMS was not designed nor is it
currently configured for people who do not need hospital care,
including nursing home residents. As stated in the memorandum of
agreement among the NDMS federal partners, the patient evacuation
function of NDMS is intended to move patients so that they can
receive medical care in NDMS hospitals-typically nonfederal
hospitals that have agreements with NDMS. NDMS officials told us
that they do not have agreements with nursing homes or other types
of health care providers. However, because of the immediate
demands posed by Hurricane Katrina, federal officials told us that
NDMS had to move people who did not need hospital care, including
nursing home residents and members of the general public who
arrived at NDMS mobilization centers. NDMS flights evacuated
people with various needs from mobilization centers to NDMS
patient reception areas where officials assessed their health
needs and arranged for them to receive additional medical care
through the definitive care portion of NDMS. NDMS reception areas
had to make special arrangements for people in need of nursing
home care, because NDMS lacked preexisting agreements with nursing
homes equipped to handle people with nonhospital health care
needs.32 In a report prepared by NDMS after the hurricane, federal
officials noted that NDMS was not optimally prepared to manage the
nursing home requirements of evacuees who did not require
hospitalization.33 The movement of nursing home residents during
evacuations is not addressed elsewhere in the NRP.
At the federal level, CMS has requirements related to hospital and
nursing home disaster and evacuation planning as a condition of
participation in the Medicare and Medicaid programs. For
hospitals, a CMS requirement states that the overall hospital
environment must be maintained to assure the safety and well-being
of patients.34 According to CMS guidelines for interpreting this
regulation, hospitals must develop and maintain comprehensive
emergency plans, and when developing plans, should consider the
transfer of patients to other health care settings or hospitals if
necessary. For nursing homes, a CMS regulation states that
facilities must have plans to meet all potential emergencies and
disasters, although the interpretative guidelines do not
specifically mention transfer of residents.35 CMS officials told
us that, based on experiences during Hurricane Katrina, they have
established a work group within CMS to review hospital and nursing
home requirements and other provider standards, policies, and
guidance related to emergency preparedness, including issues
related to evacuations. The officials told us that they expect the
work group to make initial recommendations for improvement in
2006. (See app. II for CMS regulations and interpretive guidelines
related to evacuation planning and emergency preparedness.)
In addition to CMS requirements, JCAHO, AOA, and states can
establish additional emergency management requirements for health
care facilities. For hospitals that it accredits, JCAHO requires
that emergency plans include provisions for evacuating the entire
building and transporting patients, supplies, staff, and equipment
to alternate care sites if necessary.36 AOA requires that
emergency plans for hospitals that it accredits include provisions
for transferring patients and supplies to other settings for
health care if necessary. (See app. III for a list of JCAHO and
AOA requirements related to evacuation planning and emergency
preparedness.) States can also establish additional requirements
for facility evacuation planning that relate to transportation.
For example, Florida requires hospitals and nursing homes to have
comprehensive emergency management plans that document
transportation arrangements to be used to evacuate residents.37
Mississippi requires nursing homes to maintain written transfer
agreements with other facilities or alternative shelters in the
event of a disaster.38 The state also requires hospitals to have
written disaster preparedness plans that include relocation
arrangements, including transportation arrangements, in the event
of an evacuation.39
Federal requirements for hospitals and nursing homes include
provisions that the facilities plan for disasters and emergencies.
However, when hurricanes Charley and Katrina hit the Gulf Coast
area, they created significant challenges for health care facility
administrators that faced evacuation, including deciding whether
to evacuate, securing transportation, and maintaining
communications outside of their facilities. In particular,
securing transportation was challenging because when multiple
health care facilities within a community decided to evacuate,
they had difficulty obtaining the number and type of vehicles
needed and competed with each other for a limited supply of
vehicles.
A federal role related to evacuation is described in various
documents, including the NDMS memorandum of agreement, the NRP,
and its draft Catastrophic Incident Supplement. However, the
challenges faced by hospitals and nursing homes during hurricanes
Charley and Katrina also revealed two limitations in the federal
government's support to health care facilities that have to
evacuate-the lack of assistance to states and localities to move
people out of health care facilities to a mobilization point for
federal transportation support and the lack of attention to
nursing home residents needing evacuation. In terms of the first
limitation, we found that the reliance in the NDMS design on local
and state resources to move people directly out of facilities is
inadequate when multiple facilities in the community have to
evacuate simultaneously and compete for too few vehicles. In
addition, DHS's draft Catastrophic Incident Supplement to the NRP,
which is intended to offer guidance for a situation in which state
and local resources are overwhelmed, also would leave
responsibility for moving people out of health care facilities on
state and local authorities. It does not describe the role the
federal government may play in coordinating with state and local
authorities during hospital and nursing home evacuations. In terms
of the second limitation, we noted that the evacuation of nursing
home residents was not considered when NDMS was originally
designed in 1984-nor is it currently addressed elsewhere in the
NRP-but the experiences of these recent hurricanes also showed
that the needs of this population when evacuations are required
have been overlooked in the federal plans.
DHS is the lead agency responsible for issuance and maintenance of
the NRP, development of the draft Catastrophic Incident
Supplement, and activation of NDMS. Until it addresses these
limitations-within NDMS, the NRP, or through other
mechanisms-vulnerabilities in the evacuation of hospitals and
nursing homes will continue, and the federal government's response
will not be as effective as possible.
To address limitations in how the federal government provides
assistance with the evacuation of health care facilities, we
recommend that the Secretary of Homeland Security take the
following two actions:
o Clearly delineate how the federal government will assist state
and local governments with the movement of patients and residents
out of hospitals and nursing homes to a mobilization center where
NDMS transportation begins.
o In consultation with the other NDMS federal partners-the
Secretaries of Defense, Health and Human Services, and Veterans
Affairs-clearly delineate how to address the needs of nursing home
residents during evacuations, including the arrangements necessary
to relocate these residents.
We received written comments on a draft of this report from DHS,
DOD, HHS, and VA.
DHS stated that it will take our recommendations under advisement
as it reviews the National Response Plan. According to DHS, all of
the NDMS federal partners are currently reviewing the NDMS
memorandum of agreement with a view towards working with state and
local partners to alter, delineate, and otherwise clarify roles
and responsibilities as appropriate. DHS confirmed that the
primary responsibility for evacuations remains with state and
local governments and that the federal government becomes involved
only when the capabilities of the state and local governments are
overwhelmed. However, as stated in the draft report, neither NDMS
documents, the NRP, nor the draft Catastrophic Incident Supplement
to the NRP-to be used in cases when the capabilities of state and
local governments are almost immediately overwhelmed-describe the
federal role in coordinating with state and local authorities
during hospital and nursing home evacuations. We also noted that
reliance on state and local resources was inadequate when multiple
facilities in a community had to evacuate simultaneously. DHS's
written comments are reprinted in appendix IV.
DOD disagreed with our conclusions concerning NDMS's two
limitations. First, DOD stated that our report implies that the
provision of short-distance transportation is a federal
responsibility, but DOD maintains that it is a state and local
responsibility. However, during a catastrophic incident, the
capabilities of state and local governments may almost immediately
become overwhelmed. As we stated above in our response to DHS's
comments, the federal role in these situations has not been
described. Second, DOD stated that our conclusion regarding the
needs of nursing home residents was technically correct, but that
we failed to describe the successful evacuation of nursing home
residents during Hurricane Rita. Our draft report did describe
NDMS's evacuation of people, including nursing home residents and
other people who did not need hospital care, during recent
hurricanes due to the immediate demands posed by the storms.
However, we also noted that the NDMS after-action report on
hurricanes Katrina and Rita states that NDMS was not optimally
prepared to manage the nursing home requirements of evacuees who
did not require hospitalization. For this reason, we believe that
explicit consideration of the needs of nursing home residents is
warranted. DOD's written comments are reprinted in appendix V.
HHS concurred with our recommendations and made two general
comments. First, HHS noted that we should address the role of DOT
in the NRP to provide transportation support for domestic
emergencies. Under ESF #8, DOT can assist with identifying and
arranging for all types of transportation. However, as stated in
the draft report, the NRP does not indicate how DOT or other
federal agencies are to assist state and local authorities in
moving hospital patients and nursing home residents from their
facilities. Second, HHS commented that the report does not
describe why NDMS was designed to focus on hospital evacuation,
but HHS did not provide any additional information about NDMS's
origins. Although the draft report included available information
on the origins of NDMS, our assessment focused on the program's
current status. HHS's written comments are reprinted in appendix
VI.
VA agreed with our conclusions and recommendations and stated that
it would continue to address issues raised in the draft report.
VA's written comments are reprinted in appendix VII.
DHS and HHS also provided technical comments. In addition, DOT
provided technical comments via email. We incorporated these
comments where appropriate.
We are sending copies of this report to the Secretaries of DOD,
HHS, DHS, DOT, VA, and other interested parties. We will also make
copies available to others on request. In addition, the report
will be available at no charge on GAO's Web site at
http://www.gao.gov .
If you or your staff have any questions about this report, please
contact me at (202) 512-7101 or bascettac@gao.gov. Contact points
for our Offices of Congressional Relations and Public Affairs may
be found on the last page of this report. GAO staff who made major
contributions to this report are listed in appendix VIII.
Cynthia A. Bascetta Director, Health Care
List of Committees
The Honorable Charles E. Grassley Chairman The Honorable Max
Baucus Ranking Minority Member Committee on Finance United States
Senate
The Honorable Michael B. Enzi Chairman The Honorable Edward M.
Kennedy Ranking Minority Member Committee on Health, Education,
Labor, and Pensions United States Senate
The Honorable Susan M. Collins Chairman Committee on Homeland
Security and Governmental Affairs United States Senate
The Honorable Daniel K. Akaka Ranking Minority Member Committee on
Veterans' Affairs United States Senate
The Honorable Gordon H. Smith Chairman The Honorable Herb Kohl
Ranking Minority Member Special Committee on Aging United States
Senate
The Honorable Ike Skelton Ranking Minority Member Committee on
Armed Services House of Representatives
The Honorable Joe Barton Chairman The Honorable John D. Dingell
Ranking Minority Member Committee on Energy and Commerce House of
Representatives
The Honorable Tom Davis Chairman The Honorable Henry A. Waxman
Ranking Minority Member Committee on Government Reform House of
Representatives
The Honorable Bennie G. Thompson Ranking Minority Member Committee
on Homeland Security House of Representatives
The Honorable Steve Buyer Chairman The Honorable Lane Evans
Ranking Minority Member Committee on Veterans' Affairs House of
Representatives
The Honorable William M. Thomas Chairman The Honorable Charles B.
Rangel Ranking Minority Member Committee on Ways and Means House
of Representatives
To examine the challenges hospital and nursing home administrators
faced related to recent hurricanes, we conducted case studies in
two states-Florida and Mississippi. We selected these states based
on their experience with previous disasters. During 2004, the
state of Florida was hit by four hurricanes-Charley, Frances,
Ivan, and Jeanne. Hurricane Charley was the strongest of these
four, and the strongest hurricane to hit the United States since
Hurricane Andrew hit southern Florida in 1992.1 In 2005,
Mississippi received heavy storm damage from Hurricane Katrina
caused by wind and an extremely high storm surge.
In Florida, to understand the role of the state and local
governments in evacuating hospitals and nursing homes, we
interviewed and obtained documents from state and county
officials. At the state level, we interviewed officials from the
Florida Department of Health's Office of Emergency Operations. We
reviewed the Florida Comprehensive Emergency Management Plan, as
well as Florida's after-action report for the 2004 Hurricane
season. At the local level, we selected two counties affected by
Hurricane Charley-Charlotte and Volusia counties. Charlotte
County, the entry point for the hurricane, is located on the Gulf
Coast of Florida. Volusia County, the exit point for the
hurricane, is located on the Atlantic Coast of the state. Within
each county, we interviewed emergency management officials and
reviewed county emergency management plans.
To obtain information on the experiences of individual health care
facilities in Florida, we identified hospitals and nursing homes
within each of the selected counties, interviewed facility
administrators, and reviewed documents. To select facilities, we
asked emergency management officials in each county to provide
contact information for hospitals and nursing homes that either
evacuated or sheltered in place due to Hurricane Charley. In cases
where the representatives identified by county officials were
unavailable, we selected alternate health care facilities based on
their proximity to the ocean. For each facility, we obtained and
reviewed applicable emergency plans, hurricane plans, and/or
evacuation plans. In total, we interviewed administrators from two
hospitals and two nursing homes in Charlotte County and one
hospital and two nursing homes in Volusia County. In addition to
facility administrators, we interviewed officials from the Florida
Hospital Association, the Florida Association of Homes for the
Aging, and the Florida Health Care Association.
In Mississippi, to understand the role of the state and local
governments in evacuating hospitals and nursing homes, we
interviewed and obtained documents from state and county
officials. At the state level, we interviewed officials from the
Mississippi Emergency Management Agency and Department of Health,
and reviewed documents including the Mississippi Comprehensive
Emergency Management Plan. At the local level, we selected the two
coastal counties that were hit most directly by Hurricane
Katrina-Hancock and Harrison counties. Hancock County, which
includes the cities of Waveland and Bay St. Louis, was directly in
the path of the storm and sustained extensive damage. Harrison
County, which is adjacent to Hancock County and includes the
cities of Gulfport and Biloxi, sustained extensive damage and has
the area's largest population. In each county, we interviewed
emergency management officials. We also reviewed emergency
management plans from Hancock and Harrison counties.
To obtain information on the experience of individual health care
facilities in Mississippi, we identified hospitals, nursing homes,
and assisted living facilities within each of the selected
counties; interviewed facility administrators; and reviewed
documents provided. To locate health care facilities, we relied on
a list of hospitals, nursing homes, and assisted living facilities
in Hancock and Harrison counties from a June 2005 Mississippi
Department of Health report on hospitals2 and a September 2005
Mississippi Department of Health report on institutions for the
aged or infirm.3 We also identified facilities in Harrison County
that were operated by the Department of Veterans Affairs (VA). We
excluded nursing homes with fewer than 20 licensed beds. From this
list, we selected facilities based on ownership type,
vulnerability and proximity to the ocean, and size. For each
facility, we obtained and reviewed emergency plans, hurricane
plans, and/or evacuation plans. In total, we interviewed officials
from one hospital and one nursing home in Hancock County and four
hospitals and two assisted living facilities in Harrison County.
We also interviewed representatives from the Gulf States
Association of Homes and Services for the Aging.
To examine the extent to which limitations exist in the design of
the National Disaster Medical System (NDMS) or other federal
programs to assist state and local governments with patient
evacuations, we reviewed federal documents such as the National
Response Plan, including Emergency Support Function #8-Public
Health and Medical Services-and the Catastrophic Incident Annex.
We also obtained and reviewed a September 2005 draft of the
Catastrophic Incident Supplement to the NRP. We interviewed
emergency preparedness officials from the Department of Defense,
the Department of Health and Human Services, the Department of
Homeland Security, the Department of Transportation, and the VA.
To obtain additional information on NDMS, we reviewed program
documents, including the memorandum of agreement that governs NDMS
and an after-action report on the use of NDMS due to Hurricane
Katrina.
To examine the federal requirements for hospital and nursing home
disaster and evacuation planning, we reviewed documents that
identify the federal requirements and national standards related
to emergency management, disaster preparedness, and patient
evacuation. We reviewed documents provided by the Centers for
Medicare & Medicaid Services (CMS) and by accrediting
organizations that assess compliance with CMS requirements-the
Joint Commission on Accreditation of Healthcare Organizations and
the American Osteopathic Association. We also interviewed
officials from these organizations concerning the requirements and
enforcement mechanisms, as well as officials from the American
Hospital Association, Federation of American Hospitals, and the
American Health Care Association. In addition, we interviewed and
obtained documents from the Florida Agency for Health Care
Administration officials responsible for the licensing and
certification of health care facilities as well as officials from
the Mississippi Department of Health. We performed our work from
October 2005 through July 2006 in accordance with generally
accepted government auditing standards.
The Centers for Medicare & Medicaid Services (CMS) establishes
federal regulations that hospitals and nursing homes must meet to
participate in the Medicare and Medicaid programs. CMS's
interpretive guidelines contain authoritative interpretations and
clarifications of statutory and regulatory requirements and are to
be used to make determinations about compliance with requirements.
The tables below include regulations for hospitals and nursing
homes that relate to disaster and evacuation planning. Table 1
includes CMS regulations and interpretive guidelines for
hospitals.
18A Disaster Medical Assistance Team (DMAT) is a group of medical and
support personnel designated to provide medical care during disasters.
DMATs are designed to deploy to disaster sites with sufficient supplies
and equipment, and their responsibilities may include triaging patients
and preparing patients for evacuation.
Regulation of Hospitals and Nursing Homes
19Participating hospitals regularly report the number of beds that they
have available for NDMS patients so that VA and DOD can quickly identify
bed capacity when needed.
2042 C.F.R. pts. 482 (for hospitals) and 483 (for nursing homes) (2005).
2142 U.S.C. S: 1395bb (2000).
22In 2004, JCAHO accredited approximately 4,666 hospitals, which
represented about 95 percent of all U.S. hospital beds. AOA accredits 165
hospitals.
Federal Reports on Health Care Facility Evacuation Due to Hurricane Katrina
23The CMS State Operations Manual includes interpretive guidelines and
survey procedures for state agencies that assess compliance with CMS
regulations.
24Assistant to the President for Homeland Security and Counterterrorism,
The Federal Response to Hurricane Katrina: Lessons Learned (Feb. 23,
2006).
25U.S. House of Representatives, February 2006.
26Department of Homeland Security, Office of Inspector General, A
Performance Review of FEMA's Disaster Management Activities in Response to
Hurricane Katrina, OIG-06-32 (Washington, D.C.: Mar. 31, 2006).
27Committee on Homeland Security and Governmental Affairs, May 2006.
Facility Administrators Faced Several Challenges Related to Evacuation,
Including Deciding Whether to Evacuate, Securing Transportation, and Maintaining
Communication
Facility Administrators Faced Challenges in Deciding Whether to Evacuate or
Shelter in Place
28Meals, Ready-to-Eat are precooked meal kits developed for soldiers in
combat conditions.
Facility Administrators Had Problems Related to Transportation for Patient
Evacuations
Facility Administrators Faced Communication Challenges Due to Damage to Local
Infrastructure Caused by Hurricanes
NDMS Has Two Limitations That Constrain Its Assistance to State and Local
Governments with Patient Evacuation and Which Are Not Addressed Elsewhere in the
NRP
29See, for example, GAO, Bioterrorism: Information Technology Strategy
Could Strengthen Federal Agencies' Abilities to Respond to Public Health
Emergencies, GAO-03-139 (Washington, D.C.: May 30, 2003).
30For example, a DOT official told us that the federal government and the
state of Texas competed to obtain vehicles due to Hurricane Rita.
31NDMS, National Disaster Medical System (NDMS) After Action Review (AAR)
Report on Patient Movement and Definitive Care Operations in Support of
Hurricanes Katrina and Rita (Jan. 12, 2006).
Federal Requirements for Hospitals and Nursing Homes Include Provisions for
Having Disaster Plans and Transferring Patients Out of Hospitals
32For related information, see GAO-06-443R .
33NDMS 2006.
3442 C.F.R. S: 482.41(a) (2005).
3542 C.F.R. S: 483.75(m) (2005).
Conclusions
36However, JCAHO officials stated that, in a disaster that affects the
entire community, the requirements would not prevent multiple facilities
from competing for the same transportation resources or alternate care
sites.
37Fla. Stat. S: 395.1055(1)(c) (2005); Fla. Admin. Code Ann. r. 59A-4.126
(2005); and Emergency Mgmt. Planning Criteria for Nursing Home Facilities,
ACHA 3110-6006, March 1994.
3812-000-045 Miss. Code R. S: 405.1 (Weil 2006).
3912-000-040 Miss. Code R. S: 1401.5 (Weil 2006).
Recommendations for Executive Action
Agency Comments and Our Evaluation
Appendix I: Scope and Methodology
1Hurricane Charley was a category 4 storm on the Saffir-Simpson hurricane
rating scale. (Category 5 is the strongest possible category on the
scale.)
2Mississippi Department of Health, Division of Health Facilities Licensure
and Certification, 2004 Report on Hospitals (Jackson, Miss.: June 2005).
3Mississippi Department of Health, Bureau of Health Facilities Licensure
and Certification, 2004 Report on Institutions for the Aged or Infirm
(Jackson, Miss.: September 2005).
Appendix II: CMS Regulations and Interpretive Guidelines Related to
Hospital and Nursing Home Disaster and Evacuation
Table 1: CMS Regulation and Interpretive Guidelines for Hospitals
Regulationa Interpretive guidelinesb
42 C.F.R. S: 482.41(a) The hospital must ensure that the condition of
the physical plant and overall hospital
Buildings environment is developed and maintained in a
manner to ensure the safety and well being of
The condition of the patients. This includes ensuring that routine
physical plant and the and preventive maintenance and testing
overall hospital activities are performed as necessary, in
environment must be accordance with Federal and State laws,
developed and maintained regulations, and guidelines and manufacturer's
in such a manner that the recommendations, by establishing maintenance
safety and well being of schedules and conducting ongoing maintenance
patients are assured. inspections to identify areas or equipment in
need of repair. The routine and preventive
maintenance and testing activities should be
incorporated into the hospital's QAPIb plan.
Assuring the safety and well being of patients
would include developing and implementing
appropriate emergency preparedness plans and
capabilities. The hospital must develop and
implement a comprehensive plan to ensure that
the safety and well being of patients are
assured during emergency situations. The
hospital must coordinate with Federal, State,
and local emergency preparedness and health
authorities to identify likely risks for their
area (e.g., natural disasters, bioterrorism
threats, disruption of utilities such as water,
sewer, electrical communications, fuel; nuclear
accidents, industrial accidents, and other
likely mass casualties, etc.) and to develop
responses that will assure the safety and well
being of patients. The following issues should
be considered when developing the comprehensive
emergency plan(s):
o The differing needs of each location where
the certified hospital operates;
o The special needs of patient populations
treated at the hospital (e.g., patients with
psychiatric diagnosis, patients on special
diets, newborns, etc.);
o Security of patients and walk-in patients;
o Security of supplies from
misappropriation;
o Pharmaceuticals, food, other supplies and
equipment that may be needed during
emergency/disaster situations;
o Communication to external entities if
telephones and computers are not operating or
become overloaded (e.g., ham radio operators,
community officials, other healthcare
facilities if transfer of patients is
necessary, etc.);
o Communication among staff within the
hospital itself;
o Qualifications and training needed by
personnel, including healthcare staff,
security staff, and maintenance staff, to
implement and carry out emergency procedures;
o Identification, availability and
notification of personnel that are needed to
implement and carry out the hospital's
emergency plans;
o Identification of community resources,
including lines of communication and names
and contact information for community
emergency preparedness coordinators and
responders;
o Provisions if gas, water, electricity
supply is shut off to the community;
o Transfer or discharge of patients to home,
other healthcare settings, or other
hospitals;
o Transfer of patients with hospital
equipment to another hospital or healthcare
setting; and
o Methods to evaluate repairs needed and to
secure various likely materials and supplies
to effectuate repairs.
Source: CMS State Operations Manual.
aGAO analyzed regulations and interpretive guidelines for hospitals that
specifically pertain to evacuation planning and emergency preparedness.
For a full list of CMS regulations and interpretive guidelines for
hospitals, see the CMS State Operations Manual, Appendix A - Survey
Protocol, Regulations and Interpretive Guidelines for Hospitals.
bAccording to CMS, hospitals use a quality assessment performance
improvement (QAPI) plan to systematically examine quality and implement
specific improvement projects on an ongoing basis.
Table 2 includes CMS regulations and interpretive guidelines for nursing
homes. CMS surveyors conduct health care facility surveys to evaluate the
manner and degree to which the providers satisfy various CMS requirements
or standards. Long-term care facilities include nursing homes.
Table 2: CMS Guidance to Surveyors for Long Term Care Facilities
Regulationa Interpretive guidelinesb
42 C.F.R. S: 483.70
Physical Environment
The facility must be designed,
constructed, equipped, and
maintained to protect the health
and safety of residents, personnel
and the public.
42 C.F.R. S: 483.75
Administration
A facility must be administered in
a manner that enables it to use
its resources effectively and
efficiently to attain or maintain
the highest practicable physical,
mental, and psychosocial
well-being of each resident.
42 C.F.R. S: 483.75(m) The facility should tailor its disaster
plan to its geographic location and the
Disaster and Emergency types of residents it serves. "Periodic
Preparedness review" is a judgment made by the
facility based on its unique
1. The facility must have circumstances[.] [C]hanges in physical
detailed written plans and plan or changes external to the
procedures to meet all facility can cause a review of the
potential emergencies and disaster review plan[.]
disasters, such as fire, severe
weather, and missing residents. The purpose of a "staff drill" is to
2. The facility must train all test the efficiency, knowledge, and
employees in emergency response of institutional personnel in
procedures when they begin to the event of an emergency. Unannounced
work in the facility, staff drills are directed at the
periodically review the responsiveness of staff, and care
procedures with existing staff, should be taken not to disturb or
and carry out unannounced staff excite residents.
drills using those procedures.
Source: CMS State Operations Manual.
aGAO analyzed regulations and interpretive guidelines for nursing homes
that specifically pertain to evacuation planning and emergency
preparedness. For a full list of CMS regulations and interpretive
guidelines for nursing homes, see the CMS State Operations Manual,
Appendix PP - Guidance to Surveyors for Long Term Care Facilities.
bSome regulations do not have interpretive guidelines.
Appendix III: JCAHO and AOA Requirements for Hospital Evacuation Planning
and Emergency Preparedness
Hospitals that are accredited by the Joint Commission on Accreditation of
Healthcare Organizations (JCAHO) or the American Osteopathic Association
(AOA) are generally deemed to be compliant with the Centers for Medicare &
Medicaid Services requirements. The document and table below include JCAHO
and AOA requirements for hospitals that relate to evacuation planning and
emergency preparedness. The document includes JCAHO hospital requirements,
and table 3 includes AOA hospital requirements.
Source: JCAHO 2006 Hospital Accreditation Standards for Emergency
Management Planning, Emergency Management Drills, Infection Control, and
Disaster Privileges (c) 2005 Used with permission.
Note: GAO obtained these standards from JCAHO in November 2005. According
to JCAHO officials, parts of the standards have since been revised.
Table 3: 2005 AOA Accreditation Requirements for Hospitals
Standard Description
11.02.02 Building Safety. The hospital must ensure that the condition of
the physical plant and overall hospital
The condition of the environment is developed and maintained in a
physical plant and the manner to ensure the safety and well being of
overall hospital patients. This includes ensuring that routine
environment must be and preventive maintenance and testing
developed and maintained in activities are performed as necessary, in
such a manner that the accordance with Federal and State laws,
safety and well being of regulations, and guidelines and manufacturer's
patients, visitors, and recommendations, by establishing maintenance
staff is assured. schedules and conducting ongoing maintenance
inspections to identify areas or equipment in
need of repair. The routine and preventive
maintenance activities should be incorporated
into the hospital's QAPIa plan.
The hospital must develop and implement a
comprehensive plan to ensure that the safety
and well being of patients are assured during
emergency situations. The hospital must
coordinate with Federal, State, and local
emergency preparedness and health authorities
to identify likely risks for their area (e.g.,
natural disaster, bioterrorism threats,
disruption of utilities such as water, sewer,
electrical communications, fuel; nuclear
accidents, industrial accidents, and other
likely mass casualties, etc.) and to develop
appropriate responses that will assure that
safety and well being of patients.
The following issues should be considered when
developing the comprehensive emergency plans:
a. The differing needs of each location where
the certified hospital operates
b. The special needs of patient populations
treated at the hospital (e.g., patients with
psychiatric diagnosis)
c. Security of patients and walk-in patients
d. Security of supplies from misappropriation
e. Pharmaceuticals, food, other supplies and
equipment that may be needed during
emergency/disaster situations
f. Communication to external entities if
telephones and computers are not operating
emergency/disaster situations or become
overloaded (e.g., ham radio operators,
community officials, other healthcare
facilities if transfer of patients is
necessary, etc.)
g. Communication among staff within the
hospital itself
h. Qualifications and training needed by
personnel including healthcare staff, security
staff, and maintenance staff, to implement and
carry out emergency procedures
i. Identification, availability and
notification of personnel that are needed to
implement and carry out the hospital's
emergency plans
j. Identification of community resources,
including lines of communication and names and
contact information for community emergency
preparedness coordinators and responders
k. Provisions if gas, water, electricity
supply is shut off to the community
l. Transfer or discharge of patients to home,
other healthcare settings, or other hospitals
m. Transfer of patients with hospital
equipment to another hospital or healthcare
setting; and
n. Methods to evaluate repairs needed and to
secure various likely materials and supplies
to effectuate repairs
11.07.01 Disaster Plans. All disaster plans written by a hospital
should be reviewed and coordinated with local
Written disaster plans are authorities so as to prevent confusion. Such
developed, maintained, and authorities include, but are not limited to,
available to the staff for civil authorities (such as fire department,
crisis preparation police department, public health department or
emergency medical service councils), and civil
defense or military authorities. The hospital
shall provide an education program for staff
and physicians for emergency response
preparedness. The hospital should also
participate in community emergency
preparedness plans.
11.07.02 External Disaster The hospital's external disaster plan shall
Plan-Victim Triage. include the triaging of victims and includes
at least:
a. identification tags
b. placement of patients
c. notification of physicians; and
d. preliminary diagnosis of patients
The plan must address handling of communicable
disease outbreaks and chemical exposure
victims.
11.07.03 Disaster Drills. Disaster drills are to be performed at least
semiannually one of which shall include the
community.
11.08.03 Maintenance Facilities must be maintained to ensure an
Ensures Safety and Quality. acceptable level of safety and quality.
Facilities, supplies, and Supplies must be maintained to ensure an
equipment shall be acceptable level of safety and quality. This
maintained to ensure an would include that supplies are stored in such
acceptable level of safety a manner to ensure the safety of the stored
and quality. supplies (protection against theft or damage,
contamination, or deterioration), as well as,
that the storage practices do not violate fire
codes or otherwise endanger patients (storage
of flammables, blocking passageways, storage
of contaminated or dangerous materials, safe
storage practices for poisons, etc.)
Additionally, "supplies must be maintained to
ensure an acceptable level of safety" would
include that the hospital identifies the
supplies it needs to meet its patients' needs
for both day-to-day operations and those
supplies that are likely to be needed in
likely emergency situations such as mass
casualty events resulting from natural
disasters, mass trauma, disease outbreaks,
etc.; and that the hospital makes adequate
provisions to ensure the availability of those
supplies when needed.
Medical equipment and other equipment must be
maintained in accordance with manufacturers
recommendations, laws, and NFPAb 99 chapters
as appropriate.
Equipment includes both hospital equipment
(e.g., elevators, generators, air handlers,
medical gas systems, air compressors and
vacuum systems, etc.) and medical equipment
(e.g., biomedical equipment, radiological
equipment, patient beds, stretchers, IV
infusion equipment, ventilators, laboratory
equipment, etc.).
There must be a regular periodical maintenance
and testing program for medical devices and
equipment. A qualified individual such as a
clinical or biomedical engineer, or other
qualified maintenance person must monitor,
test, calibrate and maintain the equipment
periodically in accordance with the
manufacturer's recommendations and federal and
State laws and regulations. Equipment
maintenance may be conducted using hospital
staff, contracts, or through a combination of
hospital staff and contracted services.
"Equipment must be maintained to ensure an
acceptable level of safety" would include that
the hospital identifies the equipment it needs
to meet its patients' needs for both
day-to-day operations and equipment that is
likely to be needed in likely
emergency/disaster situations such as mass
casualty events resulting from natural
disasters, mass trauma, disease outbreaks,
internal disasters, etc.; and that the
hospital makes adequate provisions to ensure
the availability of that equipment when
needed.
Source: Accreditation Requirements for Healthcare Facilities (c) 2005,
Healthcare Facilities Accreditation Program (HFAP) of the American
Osteopathic Association. Used with permission.
aQuality assessment performance improvement.
bNational Fire Protection Association.
Appendix IV: Comments from the Department of Homeland Security
Appendix V: Comments from the Department of Defense
Appendix VI: Comments from the Department of Health and Human Services
Appendix VII: Comments from the Department of Veterans Affairs
Appendix VIII: GAO Contact and Staff Acknowledgments
GAO Contact
Cynthia A. Bascetta at (202) 512-7101 or bascettac@gao.gov
Acknowledgments
In addition to the contact named above, key contributors to this report
were Linda T. Kohn, Assistant Director; La Sherri Bush; Krister Friday;
Nkeruka Okonmah; and William Simerl.
Related GAO Products Related GAO Products
Disaster Preparedness: Preliminary Observations on the Evacuation of
Vulnerable Populations due to Hurricanes and Other Disasters. GAO-06-790T
. Washington, D.C.: May 18, 2006.
Hurricane Katrina: Status of the Health Care System in New Orleans and
Difficult Decisions Related to Efforts to Rebuild It Approximately 6
Months After Hurricane Katrina. GAO-06-576R . Washington, D.C.: March 28,
2006.
Hurricane Katrina: GAO's Preliminary Observations Regarding Preparedness,
Response, and Recovery. GAO-06-442T . Washington, D.C.: March 8, 2006.
Disaster Preparedness: Preliminary Observations on the Evacuation of
Hospitals and Nursing Homes Due to Hurricanes. GAO-06-443R . Washington,
D.C.: February 16, 2006.
HHS Bioterrorism Preparedness Programs: States Reported Progress but Fell
Short of Program Goals for 2002. GAO-04-360R . Washington, D.C.: February
10, 2004.
Bioterrorism: Public Health Response to Anthrax Incidents of 2001.
GAO-04-152 . Washington, D.C.: October 15, 2003.
Hospital Preparedness: Most Urban Hospitals Have Emergency Plans but Lack
Certain Capacities for Bioterrorism Response. GAO-03-924 . Washington,
D.C.: August 6, 2003.
Bioterrorism: Information Technology Strategy Could Strengthen Federal
Agencies' Abilities to Respond to Public Health Emergencies. GAO-03-139 .
Washington, D.C.: May 30, 2003.
Bioterrorism: Preparedness Varied across State and Local Jurisdictions.
GAO-03-373 . Washington, D.C.: April 7, 2003.
(290503)
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Highlights of GAO-06-826 , a report to congressional committees
July 2006
DISASTER PREPAREDNESS
Limitations in Federal Evacuation Assistance for Health Facilities Should
be Addressed
Hurricane Katrina demonstrated difficulties involved in evacuating
communities and raised questions about how hospitals and nursing homes
plan for evacuations and how the federal government assists. Due to
broad-based congressional interest, GAO assessed the evacuation of
hospital patients and nursing home residents. Under the Comptroller
General's authority to conduct evaluations on his own initiative, GAO
examined (1) the challenges hospital and nursing home administrators
faced, (2) the extent to which limitations exist in the design of the
National Disaster Medical System (NDMS) to assist with patient
evacuations, and (3) the federal requirements for hospital and nursing
home disaster and evacuation planning. GAO reviewed documents and
interviewed federal officials, and interviewed hospital and nursing home
administrators and state and local officials in areas affected by
Hurricane Katrina in Mississippi and Hurricane Charley in Florida.
What GAO Recommends
GAO recommends that DHS clearly delineate (1) how the federal government
will assist state and local governments with the transportation of
patients and residents out of hospitals and nursing homes, and (2) how to
address the needs of nursing home residents during evacuations. In its
comments, DHS stated that it will take the recommendations under
advisement as it revises the NRP.
Hospital and nursing home administrators faced several challenges related
to evacuations during recent hurricanes, including deciding whether to
evacuate or stay in their facilities and "shelter in place", obtaining
transportation necessary for evacuations, and maintaining communication
outside of their facilities. Administrators took steps to ensure that
their facilities had needed resources-including staff, supplies, food,
water, and power-to provide care during the hurricane and maintain
self-sufficiency immediately after. However, when evacuations were needed,
facility administrators said that they had problems with transportation,
such as securing the vehicles needed to evacuate patients. Although
facility administrators had contracts with transportation companies,
competition for the same pool of vehicles created supply shortages when
multiple facilities in a community had to be evacuated. In addition,
communication was impaired by hurricane damage. For example, a nursing
home in Florida was unable to communicate with local emergency managers.
NDMS is a partnership of four federal agencies, and has two limitations in
its design that constrain its assistance to state and local governments
with patient evacuation. The NDMS partners are the Department of Defense,
the Department of Health and Human Services (HHS), the Department of
Homeland Security (DHS), and the Department of Veterans Affairs; DHS is
the lead agency. The first limitation is that NDMS evacuation efforts
begin at a mobilization center, such as an airport, and do not include
short-distance transportation assets, such as ambulances or helicopters,
to move patients out of health care facilities to mobilization centers.
The second limitation is that NDMS supports the evacuation of patients
needing hospital care; the program was not designed nor is it currently
configured to move people who do not require hospitalization, such as
nursing home residents. Although NDMS moved nursing home residents due to
Hurricane Katrina who were brought to mobilization centers, NDMS officials
had to make special arrangements for people in need of nursing home care
because NDMS lacked preexisting agreements with nursing homes. Neither of
these limitations is addressed in other documents GAO reviewed, including
DHS's National Response Plan (NRP).
At the federal level, HHS's Centers for Medicare & Medicaid Services (CMS)
has requirements related to hospital and nursing home evacuation planning
as a condition of participation in the Medicare and Medicaid programs. CMS
requires that hospitals maintain the overall hospital environment to
assure patient safety, including developing plans that consider the
transfer of patients to other health care settings. For nursing homes, CMS
requires that plans meet all potential emergencies and disasters; however,
requirements do not specifically mention the transfer of residents. In
addition to assessing compliance with CMS requirements, the Joint
Commission on Accreditation of Healthcare Organizations, the American
Osteopathic Association, and states can also have additional emergency
management requirements.
*** End of document. ***