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

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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 [email protected]. 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 [email protected]

                                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. ***