Status of Implementation of GAO Recommendations on Evacuation of 
Transportation-Disadvantaged Populations and Patients and	 
Residents of Health Care Facilities (01-APR-08, GAO-08-544R).	 
                                                                 
Many of the approximately 100,000 people who did not evacuate	 
before Hurricane Katrina struck the Gulf Coast in 2005 lacked	 
access to a vehicle. In the aftermath of the storm, questions	 
were raised about how well federal, state, and local governments 
were prepared to evacuate such transportation-disadvantaged	 
populations. Hurricane Katrina, which ultimately resulted in over
1,300 deaths, also demonstrated difficulties for evacuating	 
hospital patients and nursing home residents and raised questions
about the role of the federal government in assisting in such	 
evacuations. While responding to disasters and managing 	 
evacuations is largely a state and local responsibility, the	 
federal government can provide assistance when state and local	 
governments are overwhelmed. The federal government also provides
grants and technical assistance for disaster preparedness. In	 
January 2008, the Department of Homeland Security (DHS) released 
the National Response Framework (NRF)--replacing the National	 
Response Plan. Its annexes detail the roles and responsibilities 
of local, state, and federal agencies during emergencies. The	 
Federal Emergency Management Agency (FEMA), within DHS, is the	 
lead coordinating agency for federal emergency assistance. The	 
NRF details the responsibilities of supporting federal agencies, 
including the Department of Transportation (DOT), whose 	 
responsibilities include coordinating the restoration and	 
recovery of transportation systems and infrastructure, and the	 
Department of Health and Human Services (HHS), whose		 
responsibilities include coordinating public health and medical  
services. The federal government can provide medical resources,  
such as emergency medical care and the evacuation of hospital	 
patients during disasters, through the National Disaster Medical 
System (NDMS), a partnership of DHS, the Department of Defense,  
the Department of Veterans Affairs, and HHS. Recently, Congress  
expressed concerns about the extent to which GAO's		 
recommendations have been implemented and asked us to assess the 
progress these agencies have made in doing so.			 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-08-544R					        
    ACCNO:   A81485						        
  TITLE:     Status of Implementation of GAO Recommendations on       
Evacuation of Transportation-Disadvantaged Populations and	 
Patients and Residents of Health Care Facilities		 
     DATE:   04/01/2008 
  SUBJECT:   Disadvantaged persons				 
	     Disaster planning					 
	     Disaster recovery					 
	     Disaster recovery plans				 
	     Disaster relief aid				 
	     Emergency preparedness programs			 
	     Emergency response plans				 
	     Emergency response procedures			 
	     Evacuation 					 
	     Evacuation plans					 
	     Federal grants					 
	     Interagency relations				 
	     Local governments					 
	     Natural disasters					 
	     Program evaluation 				 
	     Program management 				 
	     Public assistance programs 			 
	     Public health					 
	     State governments					 
	     Strategic planning 				 
	     Program goals or objectives			 
	     Program implementation				 
	     National Disaster Medical System			 
	     National Response Framework			 
	     National Response Plan				 

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GAO-08-544R

   

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GAO-08-544R: 

United States Government Accountability Office: 
Washington, DC 20548: 

April 1, 2008: 

The Honorable Herb Kohl:
Chairman:
Special Committee on Aging:
United States Senate: 

The Honorable John D. Dingell:
Chairman:
Committee on Energy and Commerce:
House of Representatives: 

Subject: Status of Implementation of GAO Recommendations on Evacuation 
of Transportation-Disadvantaged Populations and Patients and Residents 
of Health Care Facilities: 

Many of the approximately 100,000 people who did not evacuate before 
Hurricane Katrina struck the Gulf Coast in 2005 lacked access to a 
vehicle. In the aftermath of the storm, questions were raised about how 
well federal, state, and local governments were prepared to evacuate 
such transportation-disadvantaged populations. Hurricane Katrina, which 
ultimately resulted in over 1,300 deaths, also demonstrated 
difficulties for evacuating hospital patients and nursing home 
residents and raised questions about the role of the federal government 
in assisting in such evacuations. While responding to disasters and 
managing evacuations is largely a state and local responsibility, the 
federal government can provide assistance when state and local 
governments are overwhelmed. The federal government also provides 
grants and technical assistance for disaster preparedness. 

In January 2008, the Department of Homeland Security (DHS) released the 
National Response Framework (NRF)--replacing the National Response 
Plan. Its annexes detail the roles and responsibilities of local, 
state, and federal agencies during emergencies.[Footnote 1] The Federal 
Emergency Management Agency (FEMA), within DHS, is the lead 
coordinating agency for federal emergency assistance. The NRF details 
the responsibilities of supporting federal agencies, including the 
Department of Transportation (DOT), whose responsibilities include 
coordinating the restoration and recovery of transportation systems and 
infrastructure, and the Department of Health and Human Services (HHS), 
whose responsibilities include coordinating public health and medical 
services. The federal government can provide medical resources, such as 
emergency medical care and the evacuation of hospital patients during 
disasters, through the National Disaster Medical System (NDMS), a 
partnership of DHS, the Department of Defense, the Department of 
Veterans Affairs, and HHS. 

In 2006, we issued two reports addressing the evacuation of 
transportation-disadvantaged populations and patients and residents of 
health care facilities.[Footnote 2] 

* Our December 2006 report addressed the preparedness of state and 
local governments to evacuate transportation-disadvantaged populations 
and gaps that existed in federal assistance. The highlights of that 
report are shown in enclosure I, and the complete report may be found 
at [hyperlink, http://www.gao.gov/new.items/d0744.pdf]. Our December 
2006 report made three recommendations to the Secretary of DHS and one 
recommendation to the Secretary of DOT.[Footnote 3] 

* Our July 2006 report addressed the challenges faced by hospital and 
nursing home administrators in evacuating patients and residents of 
health care facilities and limitations in the design of NDMS that need 
clarification. The highlights of that report are shown in enclosure II, 
and the complete report may be found at [hyperlink, 
http://www.gao.gov/new.items/d06826.pdf]. Our July 2006 report made two 
recommendations to the Secretary of DHS.[Footnote 4] 

Recently, you expressed concerns about the extent to which our 
recommendations have been implemented and asked us to assess the 
progress these agencies have made in doing so. To address your 
concerns, we reviewed relevant agency documentation, including reports, 
planning guidance, and program documentation, and interviewed officials 
at DHS, DOT, and HHS. We conducted this performance audit from October 
2007 to March 2008 in accordance with generally accepted government 
auditing standards. Those standards require that we plan and perform 
the audit to obtain sufficient, appropriate evidence to provide a 
reasonable basis for our findings and conclusions based on our audit 
objectives. We believe that the evidence obtained provides a reasonable 
basis for our findings and conclusions based on our audit objectives. 

Summary: 

We found that progress implementing our recommendations has been mixed. 
Of the six recommendations contained in the two reports, two 
recommendations have been substantially implemented, while three 
recommendations have been partially implemented, and one recommendation 
has not been implemented. 

Table 1 summarizes the six recommendations made in the two reports and 
the status of implementation. We provided a briefing to your staffs in 
February 2008 on the status of the implementation of these 
recommendations. That briefing provides additional details on the 
actions DHS, DOT, and HHS have taken and may be found in enclosure III 
of this report. 

Table 1: GAO Recommendations and Status of Implementation: 

DHS: Clarify, in the National Response Plan, that FEMA is the lead and 
coordinating agency for providing evacuation assistance when state and 
local governments are overwhelmed and also clarify the responsibilities 
of supporting federal agencies. (See enc. III, slide 8.)
Partially implemented. 

DHS: Require that, as part of DHS grant programs, state and local 
governments plan, train, and conduct exercises for the evacuation of 
transportation-disadvantaged populations. (See enc. III, slide 9.)
Not implemented. 

DHS: Improve technical assistance to state and local governments by (a) 
providing more detailed guidance on how to plan, train, and conduct 
exercises for evacuating transportation-disadvantaged populations and 
(b) improving the organization and search functions of its online 
information sharing portal used by federal, state, and local officials. 
(See enc. III, slides 10 and 11).
Partially implemented. 

DOT: Encourage the department's grant recipients and stakeholders to 
share information that would assist emergency management and 
transportation officials in identifying and locating, as well as 
determining the evacuation needs of and providing transportation for, 
transportation- disadvantaged populations. (See enc. III, slide 12.)
Substantially implemented. 

HHS and DHS[A]: Clearly delineate how the federal government will 
assist state and local governments with moving patients and residents 
from hospitals and nursing homes to a mobilization center, where NDMS 
transportation begins. (See enc. III, slide 16.)
Substantially implemented. 

HHS and DHS[A]: In consultation with the other NDMS partners, clearly 
delineate how to address the needs of nursing home residents during 
evacuations, including the arrangements necessary to relocate these 
residents. (See enc. III, slide 17.)
Partially implemented. 

Source: GAO Analysis: 

[A] In January 2007, the Pandemic and All-Hazards Preparedness Act 
transferred primary authority for NDMS from DHS to HHS. Our July 2006 
report made these recommendations to DHS, but HHS and DHS are 
collaborating to implement them. 

[End of table] 

Agency Comments and Our Evaluation: 

We provided a draft of this report to the Secretaries of DHS, DOT, and 
HHS. The Department of Transportation provided written comments that we 
incorporated as appropriate and Health and Human Services did not 
provide any comments. The Department of Homeland Security provided 
written comments in response to our draft, which are reproduced in 
enclosure IV. DHS disagreed with our assessment that it "did not 
implement" GAO's recommendation that DHS require that, as part of its 
grant programs, state and local governments plan, train, and conduct 
exercises for the evacuation of transportation-disadvantaged 
populations. DHS stated that it has taken a number of steps to address 
this recommendation, including: defining "special needs populations" in 
the NRF and integrating special needs populations considerations 
throughout the NRF; developing guidance documents to assist state, 
local, and tribal emergency management managers meet the needs of 
special needs populations; and incorporating special needs 
considerations into DHS grant guidance. We recognize the efforts that 
DHS has taken to address these issues and agree that DHS has taken 
steps to increase awareness and consideration of transportation- 
disadvantaged population issues. However, DHS does not require that 
grant recipients plan, train, and conduct exercises for the evacuation 
of transportation-disadvantaged populations, as stated in our 
recommendation. We therefore continue to maintain that DHS has not 
implemented this recommendation. 

As agreed with your offices, unless you publicly announce the contents 
of this report earlier, we plan no further distribution until 30 days 
from the date of this letter. At that time, we will send copies of this 
report to interested congressional committees and to the Secretaries of 
DHS, DOT, and HHS. We will also make copies available to others upon 
request. In addition, this report will be available at no charge on 
GAO's web site, [hyperlink, http://www.gao.gov]. 

If you or your staff have any questions on matters discussed in this 
report, please contact David Wise at (202) 512-5731 or [email protected] 
for issues related to transportation-disadvantaged populations or 
Cynthia A. Bascetta at (202) 512-7207 or [email protected] for issues 
related to hospitals and nursing homes. Contact points for our Offices 
of Congressional Relations and Public Affairs may be found on the last 
page of this report. Key contributors to this report include Steve 
Cohen, Assistant Director; Linda Kohn, Assistant Director; Colin 
Fallon; Marisa London; Matthew Rosenberg; and Will Simerl. 

Signed by: 

David Wise: 
Acting Director, Physical Infrastructure Issues: 

Signed by: 

Cynthia A. Bascetta:
Director, Health Care: 

[End of correspondence] 

Enclosures: 

Enclosure I: Highlights of GAO-07-44: 

GAO Highlights: 

Highlights of GAO-07-44, a report to congressional committees. 

Why GAO Did This Study: 

During the evacuation of New Orleans in response to Hurricane Katrina 
in 2005, many of those who did not own a vehicle and could not evacuate 
were among the over 1,300 people who died. This raised questions about 
how well state and local governments, primarily responsible for 
disaster planning, integrate transportation-disadvantaged populations 
into such planning. GAO assessed the challenges and barriers state and 
local officials face; how prepared these governments are and steps they 
are taking to address challenges and barriers; and federal efforts to 
provide evacuation assistance. GAO reviewed evacuation plans; 
Department of Homeland Security (DHS), Department of Transportation 
(DOT), and other studies; and interviewed officials in five major city 
and four state governments. 

What GAO Found: 

State and local governments face evacuation challenges in identifying 
and locating transportation-disadvantaged populations, determining 
their needs, and providing for their transportation. These populations 
are diverse and constantly changing, and information on their location 
is often not readily available. In addition, these populationsï¿½ 
evacuation needs vary widely; some require basic transportation while 
others need accessible equipment, such as buses with chair lifts. Legal 
and social barriers impede addressing these evacuation challenges. For 
example, transportation providers may be unwilling to provide 
evacuation assistance because of liability concerns. 

State and local governments are generally not well preparedï¿½in terms of 
planning, training, and conducting exercisesï¿½to evacuate transportation-
disadvantaged populations, but some have begun to address challenges 
and barriers. For example, DHS reported in June 2006 that only about 10 
percent of state and about 12 percent of urban area emergency plans it 
reviewed adequately addressed evacuating these populations. 
Furthermore, in one of five major cities GAO visited, officials 
believed that few residents would require evacuation assistance despite 
the U.S. Census reporting 16.5 percent of car-less households in that 
major city. DHS also found that most states and urban areas 
significantly underestimated the advance planning and coordination 
required to effectively address the needs of persons with disabilities. 
Steps being taken by some such governments include collaboration with 
social service and transportation providers and transportation planning 
organizationsï¿½some of which are DOT grantees and stakeholdersï¿½to 
determine transportation needs and develop agreements for emergency use 
of drivers and vehicles. 

The federal government provides evacuation assistance to state and 
local governments, but gaps in this assistance have hindered many of 
these governmentsï¿½ ability to sufficiently prepare for evacuations. 
This includes the lack of any specific requirement to plan, train, and 
conduct exercises for the evacuation of transportation-disadvantaged 
populations as well as gaps in the usefulness of DHSï¿½s guidance. 
Although federal law requires that state and local governments with 
mass evacuation plans incorporate special needs populations into their 
plans, this requirement does not necessarily ensure the incorporation 
of all transportation-disadvantaged populations. Additionally, while 
DHS has made improvements to an online portal for sharing related 
information, this information remains difficult to access because of 
poor search and organizational functions. Moreover, although the 
federal government can provide evacuation assistance when state and 
local governments are overwhelmed, the federal government is not 
prepared to do so. Amendments to the Stafford Act in October 2006 
affirmed that FEMA (an agency within DHS) is responsible for leading 
and coordinating evacuation assistance. DHS has not yet clarified, in 
the National Response Plan, the lead, coordinating, or supporting 
agencies in such cases. 

What GAO Recommends: 

DHS should clarify federal agenciesï¿½ roles and responsibilities for 
providing evacuation assistance when state and local governments are 
overwhelmed. DHS should require state and local evacuation preparedness 
for transportation-disadvantaged populations and improve information to 
assist these governments. DOT should encourage its grant recipients to 
share information to assist in evacuation preparedness for these 
populations. DOT and DHS agreed to consider our recommendations, and 
DHS stated it has partly implemented some of them. 

[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-44]. 

To view the full product, including the scope and methodology, click on 
the link above. For more information, contact Kate Siggerud at (202) 
512-2834 or [email protected]. 

[End of enclosure] 

Enclosure II: Highlights of GAO-06-826: 

GAO Highlights: 

Highlights of GAO-06-826, a report to congressional committees. 

Why GAO Did This Study: 

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 
Generalï¿½s 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 Found: 

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 ï¿½shelter in placeï¿½, 
obtaining transportation necessary for evacuations, and maintaining 
communication outside of their facilities. Administrators took steps to 
ensure that their facilities had needed resourcesï¿½including staff, 
supplies, food, water, and powerï¿½to 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 
DHSï¿½s National Response Plan (NRP). 

At the federal level, HHSï¿½s 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. 

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. 

[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-06-826]. 

To view the full product, including the scope and methodology, click on 
the link above. For more information, contact Cynthia A. Bascetta at 
(202) 512-7101 or [email protected]. 

[End of enclosure] 

Enclosure III: Briefing on the Status of GAO Recommendations: 

Transportation-Disadvantaged Populations: 

Status of Implementation of GAO Recommendations: 

Briefing for Staff: 

Special Committee on Aging, U.S. Senate: 
Committee on Energy and Commerce: 
House of Representatives: 

February 5, 2008: 

Overview: 

* Objective, Scope, and Methodology; 

* Status of Implementation of Recommendations; 

* December 2006 report: Transportation-Disadvantaged Populations: 
Actions Needed to Clarify Responsibilities and Increase Preparedness 
for Evacuations: 
- Objectives; 
- Findings; 
- Recommendations; 
- Status of implementation of recommendations. 

* July 2006 report: Disaster Preparedness: Limitations in Federal 
Evacuation Assistance for Health Facilities Should be Addressed: 
- Objectives; 
- Findings; 
- Recommendations; 
- Status of implementation of recommendations. 

Objective, Scope, and Methodology: 

Objective: To follow up on recommendations made to DHS and DOT 
regarding the evacuation of transportation-disadvantaged populations. 
[Footnote 5] 

Scope: DHS, DOT, and HHS progress since our December 2006 and July 2006 
reports. 

Methodology: Collected and analyzed relevant documentation, such as 
reports, planning guidance, and program documentation pertaining to 
actions addressing our recommendations. Met with relevant officials at 
DHS, DOT, and HHS. 

We conducted this performance audit from October 2007 to February 2008 
in accordance with generally accepted government auditing standards. 
Those standards require that we plan and perform the audit to obtain 
sufficient, appropriate evidence to provide a reasonable basis for our 
findings and conclusions based on our audit objectives. We believe that 
the evidence obtained provides a reasonable basis for our findings and 
conclusions based on our audit objectives. 

Table: Status of Implementation of Recommendations: 

DHS: Clarify Roles in National response Plan; 
Partially implemented. 

DHS: Require grant recipients to plan, train, and conduct evacuation 
exercises; 
Not implemented. 

DHS: technical assistance to facilitate information sharing; 
Partially implemented. 

DOT: Encourage grant recipients to share information; 
Partially implemented. 

HHS: Clarify Roles in Moving Patients and Residents; 
Substantially implemented. 

HHS: Clarify How to Address Nursing Home Residents' Needs; 
Substantially implemented. 

Source: GAO. 

[End of table] 

Evacuation of Transportation-Disadvantaged Populationsï¿½Reporting 
Objectives: 

* What challenges do state and local governments face in preparing for 
the evacuation of transportation-disadvantaged populations? 

* How prepared are state and local governments to evacuate 
transportation-disadvantaged populations? 

* How has the federal government assisted state and local governments 
in evacuating transportation-disadvantaged populations? 

[from GAO, Transportation-Disadvantaged Populations: Actions Needed to 
Clarify Responsibilities and Increase Preparedness for Evacuations, GAO-
07-44 (Washington, D.C.: Dec. 22, 2006)] 

Evacuation of Transportation-Disadvantaged Populationsï¿½Report Findings: 

* Challenges include difficulty in identifying and locating 
transportation-disadvantaged populations, as well as legal and social 
barriers. 

* State and local governments are generally not well prepared to 
evacuate transportation-disadvantaged populations. 

*While the federal government assists state and local governments in 
evacuations, gaps exist in federal assistance. 

[from GAO, Transportation-Disadvantaged Populations: Actions Needed to 
Clarify Responsibilities and Increase Preparedness for Evacuations, GAO-
07-44 (Washington, D.C.: Dec. 22, 2006)] 

Evacuation of Transportation-Disadvantaged Populationsï¿½Report 
Recommendations: 

To DHS: 

1) Clarify, in the National Response Plan, that FEMA is the lead and 
coordinating agency to provide evacuation assistance when state and 
local governments are overwhelmed, and also clarify the supporting 
federal agencies and their responsibilities. 

2) Require that, as part of its grant programs, all state and local 
governments plan, train, and conduct exercises for the evacuation of 
transportation-disadvantaged populations. 

3) Improve technical assistance by (1) working with DOT to provide more 
detailed guidance and technical assistance on how to plan, train, and 
conduct exercises for evacuating transportation-disadvantaged 
populations; and (2) continuing to improve the organization of and 
search functions for its Lessons Learned Information Sharing online 
portal to better facilitate access to information on evacuations of 
transportation-disadvantaged for federal, state, and local officials. 

To DOT: 

4) Encourage DOTï¿½s grant recipients and stakeholders, through guidance 
and outreach, to share information that would assist emergency 
management and transportation officials in identifying and locating, as 
well as determining the evacuation needs of and providing 
transportation for, transportation-disadvantaged populations. 

[from GAO, Transportation-Disadvantaged Populations: Actions Needed to 
Clarify Responsibilities and Increase Preparedness for Evacuations, GAO-
07-44 (Washington, D.C.: Dec. 22, 2006)] 

Recommendation 1: Clarification of Roles in National Response Plan: 

* Partially Implemented. Draft Mass Evacuation Incident Annex to the 
National Response Framework appears to clarify role of FEMA and 
supporting federal agencies.
- Draft Mass Evacuation Annex designates FEMA as lead in providing 
evacuation support when federal assistance is required, clarifies the 
role of supporting federal agencies, and recognizes the need for 
planning for persons with special needs. 
- Ongoing GAO work examining clarification of other roles and 
responsibilities in NRF. 

* Responsibility for transportation services contracts and evacuation 
transportation services transferred from DOT to DHS in early 2008. 

Recommendation 2: Grants and State and Local Evacuation Exercises: 

* Not Implemented. DHS does not require grantees to plan, train, or 
conduct exercises on the evacuations of transportation-disadvantaged 
populations, though stresses importance in Homeland Security Grant 
Program (HSGP) guidance. 

* FY 2007 HSGP guidance includes evacuation planning and special needs 
populations as part of a ï¿½focus area.ï¿½ 

* No requirements in other DHS grant programs, though funds can be used 
for such purposes. 

* DHS can only track grant fund expenditures by broad Target Capability 
List categories, such as ï¿½Citizen Evacuation and Shelter-In-Placeï¿½ or 
ï¿½Planning.ï¿½ 

Recommendation 3: Technical Assistance to Facilitate Information 
Sharing: 

* Partially Implemented. DHS has developed basic guidance on the 
evacuation of special needs populations and is currently working on 
targeted guidance for states and localities. 

* Planning guide series provides general guidance to state and local 
governments: 
- Special Needs Planning Guide; 
- Evacuation Guide. 

* Gap analysis (a survey of the needs, capabilities, and shortfalls in 
state and local emergency preparedness): 
- Survey and conduct workshops with emergency response officials about 
needs, capabilities, and gaps; 
- Action plan development to address gaps; 
- Focus on sheltering and care of special needs populations, but only 
limited focus on evacuation of special needs populations. 

* Partially Implemented. DHS has improved organization and search 
function of its Lessons Learned Information System, though technical 
and functional problems remain. 

* Improvements: 
- Improved search functions and capability; 
- Search results better organized and more relevant; 
- Content improved. 

* Problems remain: 
- Content has not been added; 
- Technical issues. 

Recommendation 4: Encourage DOT Grant Recipients and Stakeholders to 
Share Information: 

* Substantially Implemented. Multiple DOT initiatives and guidance 
encourage information sharing, including: 
- Transportation Equity Research Program; 
- Conferences and Workshop Series on Evacuation Primers; 
- FHWA Final Rule on Safety in Transportation Planning. 

* Although DOT has substantially implemented this recommendation, it 
does not have a formal system to: 
- distribute resources to grant recipients and stakeholders; 
- track planning efforts for transportation-disadvantaged populations 
at state and local levels. 

Evacuation of Health Facilities Reportï¿½Reporting Objectives: 

* What challenges do hospital and nursing home administrators face in 
hurricanes? 

* What limitations exist in the design of the National Disaster Medical 
System (NDMS), a partnership of four federal agencies, to assist with 
health facility evacuation? 

* What are the federal requirements for hospital and nursing home 
disaster and evacuation planning? 

[From GAO, Disaster Preparedness: Limitations in Federal Evacuation 
Assistance for Health Facilities Should be Addressed, GAO-06-826 
(Washington, D.C.: July 20, 2006)] 

Evacuation of Health Facilities Reportï¿½Report Findings: 

* Facility administrators generally sheltered in place but had to have 
adequate supplies in order to do so. When evacuating, facility 
administrators had problems securing transportation because of supply 
shortages and had problems with communication systems. 

* NDMS and other federal programs were not designed to move patients or 
residents from facilities to a mobilization center where NDMS 
transportation could begin. 

* NDMS was not configured to evacuate people with special needs who do 
not require hospitalization, including nursing home residents. 

[From GAO, Disaster Preparedness: Limitations in Federal Evacuation 
Assistance for Health Facilities Should be Addressed, GAO-06-826 
(Washington, D.C.: July 20, 2006)] 

Evacuation of Health Facilities Reportï¿½Report Recommendations: 

To DHS: 

1) 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. 

2) In consultation with the other NDMS federal partnersï¿½the Secretaries 
of Defense, Health and Human Services, and Veterans Affairsï¿½clearly 
delineate how to address the needs of nursing home residents during 
evacuations, including the arrangements necessary to relocate these 
residents. 

* Under the Pandemic and All-Hazards Preparedness Act, primary 
authority for NDMS was transferred from DHS to HHS in January 2007. HHS 
and DHS are collaborating to implement both recommendations. 

[From GAO, Disaster Preparedness: Limitations in Federal Evacuation 
Assistance for Health Facilities Should be Addressed, GAO-06-826 
(Washington, D.C.: July 20, 2006)] 

Recommendation 1: Delineate Role of the Federal Government in Moving 
Patients and Residents from Health Facilities to Mobilization Centers: 

* Substantially Implemented. HHS and DHS collaborated with state and 
local departments of health in hurricane-prone regions to determine 
gaps between needs and available resources for hospital and nursing 
home evacuations and to determine local, state, or federal resources to 
fill the gaps. 

* Based on this analysis, HHS and DHS contracted for ground and air 
ambulances and para-transit services for Gulf and East Coast states. 

* HHS encouraged states to establish regional coalitions for mutual 
aid. 

* HHS has completed a hurricane ï¿½playbookï¿½ that improves the clarity of 
the role of federal assistance in evacuations. 

Recommendation 2: Delineate How to Address Nursing Home Residentsï¿½ 
Needs: 

* Partially Implemented. Nursing homes were included as part of the 
HHS, DHS, and state and local health department analysis of gaps and 
how to fill those gaps. 

* Vehicles obtained under HHS and DHS contractsï¿½particularly para-
transit vehiclesï¿½could be used to evacuate nursing home residents. 

* The federal role in the evacuation of nursing home residents is not 
specifically addressed in HHSï¿½s hurricane ï¿½playbook.ï¿½ 

* HHS has not provided evidence that it has clarified the role of NDMS 
in evacuating nursing home residents. 

[End of enclosure] 

Enclosure IV: Comments from the Department of Homeland Security: 

Homeland Security: 

March 19, 2008: 

Mr. David Wise: 
Acting Director: 
Physical Infrastructure Issues: 

Ms. Cynthia A. Bascetta: 
Director, Health Care: 
U.S. Government Accountability Office: 
441 G Street, NW: 
Washington, DC 20548: 

Dear Mr. Wise and Ms. Bascetta: 

RE: Draft Report 08-544R titled Status of Implementation of GAO 
Recommendations on Evacuation of Transportation-Disadvantaged 
Populations and Patients and Residents of Health Care Facilities (GAO 
Job Code 541037): 

The Department of Homeland Security (DHS) appreciates the opportunity 
to review and comment on the draft report referenced above. The report 
discusses the status of implementation of recommendations contained in 
two previously issued U.S. Government Accountability Office (GAO) 
reports. 

GAO made three recommendations to the Secretary of Homeland Security in 
GAO-07-44, Transportation-Disadvantaged Populations: Actions Needed to 
Clarify Responsibilities and Increase Preparedness for Evacuations. As 
noted in Appendix III of the draft, DHS has partially implemented two 
of the three recommendations, notably dealing with clarification of 
agency roles dealing with mass evacuations and the provision of 
technical assistance designed to facilitate information sharing. The 
report asserts that DHS has not required that, as part of our grant 
programs, all State and local governments plan, train, and conduct 
exercises for the evacuation of transportation-disadvantaged 
populations. We disagree with the last conclusion as action has been 
taken to address the recommendation. 

DHS's Office for Civil Rights and Civil Liberties (CRCL) and the 
Federal Emergency Management Agency (FEMA) have been actively 
collaborating in several areas relevant to the recommendation that DHS 
"require grantees to plan, train, or conduct exercises on the 
evacuations of transportation-disadvantaged populations." Highlights of 
work geared towards improving grantee performance with regard to the 
evacuation of transportation-disadvantaged populations include: 

(1) The National Response Framework (NRF) now includes a definition for 
the term "special needs." Special needs populations are defined as 
populations whose members may have additional needs before, during, and 
after an incident in functional areas, including but not limited to: 
maintaining independence, communication, transportation, supervision, 
and medical care. Individuals in need of additional response assistance 
may include those who have disabilities; who live in institutionalized 
settings; who are elderly; who are children; who are from diverse 
cultures; who have limited English proficiency or are non-English 
speaking; or who are transportation-disadvantaged. 

Special needs considerations as defined above are well integrated 
through the NRF base plan, Emergency Support Functions, and Annexes. 
The inclusion of specific reference to transportation-disadvantaged 
populations in the NRF will result in greater emphasis and commitment 
to meeting the needs of members of this segment of the special needs 
population. Additionally, the NRF delineates roles and responsibilities 
of key emergency planning partners at the local, Tribal, State, and 
Federal level. Among them is the responsibility to ensure that local 
emergency plans take into account the needs of individuals with special 
needs and the inclusion of special needs expertise such as groups that 
provide specialized services for special needs populations. 

(2) FEMA is working collaboratively with CRCL to revise the 
standardized guidance for the development of emergency operations plans 
(EOPS), the comprehensive preparedness guide (CPG) 101. CPG 101 
provides emergency managers and other emergency services personnel with 
DHS's best judgment and recommendations on how to address the entire 
planning process. This guide helps State, local, and Tribal emergency 
managers with their efforts to develop and maintain a viable all-hazard 
emergency operation plan. Recommendations on strategies for meeting the 
needs of special needs populations are being integrated in the revised 
CPG 101. An emergency management planning guide for special needs 
populations as defined in the NRF has been developed by FEMA in 
collaboration with CRCL and will serve as one of the several CPG 101 
companion documents. This soon to be released special needs planning 
guide articulates detailed special needs planning considerations. 

(3) DHS grant guidance incorporates special needs considerations 
including, but not limited to the definition of special needs 
populations, references to obligation under civil rights statutes, and 
helpful special needs planning resources. 

DHS continues to strongly encourage our State and local homeland 
security partners to develop planning, training, and exercise 
activities which help to strengthen preparedness efforts relative to 
various homeland security priorities, including but not limited to 
special needs populations. Our homeland security guidance has 
identified the special needs population as a direct and distinct area 
of emphasis that State and local governments should include when 
considering overall preparedness including and efforts. 

Historically, State and local units of government have developed 
emergency operations plans which contain a separate annex/focus area 
relative to special needs populations. State and local units of 
government also have conducted training and exercises which often 
contain a specific focus area directly relating to special needs 
populations. However, because special needs considerations do not exist 
in a vacuum they are typically integrated throughout other focus areas 
such as mass evacuation, public notification, interoperable 
communications, sheltering systems, and activation of primary and 
secondary emergency and operations centers. This approach allows 
responder communities to validate these numerous focus areas, overall 
plans, and training received through exercises and serves to benefit a 
greater good of accomplishing many requirements and priorities. 

GAO made two recommendations to the Secretary in GAO-06-826, Disaster 
Preparedness: Limitations in Federal Evacuation Assistance for Health 
Facilities Should be Addressed. GAO found that DHS substantially 
implemented the recommendation to delineate the role of the Federal 
government in moving patients and residents from health facilities to 
mobilization centers. GAO also found that DHS partially implemented the 
recommendation on delineating how to address nursing home residents' 
needs. 

Thank you again for the opportunity to comment on this draft report and 
we look forward to working with you on future homeland security issues. 

Sincerely, 

Signed by: 

Steven J. Pecinovsky: 
Director: 
Departmental GAO/OIG Liaison Office: 

[End of enclosure] 

Footnotes: 

[1] The NRF went into effect on March 22, 2008. 

[2] Transportation-disadvantaged populations can include numerous 
categories of people without personal vehicles, such as: the elderly 
and persons with disabilities who have mobility impairments that 
preclude them from driving or who need medical equipment in order to 
travel; low-income, homeless, or transient persons who do not have a 
permanent residence or who do not own or have access to a personal 
vehicle; children without an adult present during a disaster; tourists 
and commuters who are frequent users of public transportation; those 
with limited English proficiency who tend to rely on public transit 
more than English speakers; or those who, for any other reason, do not 
own or have access to a personal vehicle. 

[3] GAO, Transportation-Disadvantaged Populations: Actions Needed to 
Clarify Responsibilities and Increase Preparedness for Evacuations, GAO-
07-44 (Washington, D.C.: Dec. 22, 2006). 

[4] GAO, Disaster Preparedness: Limitations in Federal Evacuation 
Assistance for Health Facilities Should be Addressed, GAO-06-826 
(Washington, D.C.: July 20, 2006). 

[5] Initial GAO recommendations were made to DHS regarding the 
evacuation of health care facilities. Responsibility for these 
functions was transferred from DHS to HHS in January 2007. HHS and DHS 
are collaborating to implement both recommendations. 

[End of section] 

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