U.S. Department of Health and Human Services 
Office of Inspector General 
  
Selected Health Care 
Coalitions Increased 
NOTICE  THIS DRAFT 
RESTRICTED TO OFFICIAL  Involvement in 
USE 
 
Whole Community 
This document is a draft report of 
the Office of Inspector General 
and is subject to revision; 
therefore, recipients of this draft  Preparedness But 
should not disclose its contents for 
purposes other than for official 
review and comment under any  Face Developmental 
circumstances.  This draft and all 
copies thereof remain the property 
of, and must be returned on 
Challenges Following 
demand to, the Office of Inspector 
General. 
 
New Requirements in 
 
 
2017
 
 
 
 OEI-04-18-00080 
 April 2020 
Christi A. Grimm 
 
Principal Deputy 
oig.hhs.gov 
Inspector General  Report in Brief  U.S. Department of Health and Human Services 
April 2020 
Office  of Inspector General 
OEI-04-18-00080 
 
 
Selected Health Care Coalitions Increased 
Why OIG Did This Review 
Involvement in Whole Community Preparedness 
Health care coalitions (HCCs) help prepare 
their community health care systems to  But Face Developmental Challenges Following New 
respond to public health emergencies, such 
Requirements in 2017  
as natural disasters.  HCCs are member-led 
and are composed of health care entities 
and other response entities that voluntarily  What OIG Found  Key Takeaway 
work together to coordinate an emergency  Nearly all 20 HCCs in  More diverse health care entities are 
response.  The Office of the Assistant  our review have  participating in beneficial HCC activities.  
Secretary for Preparedness and Response  expanded their  However, new entities did not always fill gaps 
(ASPR) supports HCCs through the Hospital  membership since ASPR  in preparedness and response.  Further, training 
Preparedness Program (HPP).  In 2017, the  and CMS required  new ancillary entities pulled resources from 
HPP required HCCs to include four core  compliance with new  other priorities and reduced the incentive for 
member types (hospitals, public health,  preparedness activities  hospitals and other core members to 
emergency medical services, and  in 2017.  According to  participate. 
emergency management) and other  most of these HCCs, this   
diverse, ancillary member types (e.g., long- expansion was driven primarily by new diverse types of entities seeking to 
term-care facilities, home health agencies)  meet the CMS emergency preparedness Conditions of Participation.  Further, 
that are critical to addressing the unique  all selected HCCs reported that their members take part in HCC activities that 
preparedness needs of HCCs respective  benefit whole community emergency preparedness.   
communities.  Additionally, the Centers for 
However, HCCs also reported that expanded membership presents 
Medicare & Medicaid Services (CMS) 
challenges.  For example, some HCCs reported adding new ancillary 
suggested that health care entities join 
members without regard to their communitys needs.  Further, many HCCs 
HCCs as one way to meet its emergency 
reported concentrating their limited resources on developmental activities for 
preparedness Conditions of Participation, 
these new ancillary members, thereby lessening resources available for other 
with which CMS required compliance 
HCC priorities.  Moreover, HCCs expressed concerns about their ability to 
starting November 2017.   
continue to incentivize core members participation in HCC activities.   
This is not a review of the Federal, State, or 
Additionally, while HCCs and HPP awardees generally found ASPR guidance 
local government response to the novel 
beneficial, we found that some HPP requirements and some ASPR guidance 
coronavirus (i.e., COVID-19) public health 
are not clear.  Specifically, unclear requirements and guidance included (1) 
emergency. 
how an HCC should strategically grow membership, and (2) the flexibility that   
ASPR allows in meeting HPP membership and other requirements.  This lack 
How OIG Did This Review 
of clarity contributes to HCCs challenges and may limit HCCs ability to 
We selected a purposive sample of 20 HCCs 
prepare for a whole community response to a range of public health 
and the corresponding 20 HPP awardees 
emergencies, including emerging infectious diseases. 
that received 2017 HPP funding.  We 
What OIG Recommends and How the Agency Responded 
conducted interviews, administered surveys, 
and collected documentation from each 
To further improve HCCs preparedness for a whole community emergency 
HCC and HPP awardee from November 
response, ASPR should (1) clarify guidance that HCCs membership should  
2018 to January 2019.  We analyzed 
ensure strategic, comprehensive coverage of their communities gaps in 
responses and documentation to determine 
preparedness and response; (2) continue to work with CMS to help health 
the extent to which HCCs expanded their 
care entities comply with the CMS emergency preparedness Conditions of 
membership; to identify HCC benefits and 
Participation; (3) identify ways to incentivize core members participation; (4) 
challenges for coordinating with members; 
clarify to HPP awardees the flexibility available in meeting requirements.  
and to determine the extent to which ASPR 
ASPR concurred with all four recommendations.     
requirements and guidance facilitate HCCs 
 
and HPP awardees ability to increase whole 
community preparedness.   
  TABLE OF CONTENTS 
Background  1 
Methodology  9 
FINDINGS  10 
Nearly all 20 selected HCCs reported expanding their membership and that members  10 
participate in beneficial preparedness activities. 
However, expanded membership also presents challenges.  It has not always been done    13
strategically and has caused some HCCs to concentrate limited resources on new members.     
HCCs also face challenges in incentivizing core members participation.  14 
ASPR guidance is generally beneficial; however, some unclear 2017 Cooperative Agreement  16 
requirements and guidance contribute to HCC preparedness challenges.  
CONCLUSION AND RECOMMENDATIONS    20 
Clarify HPP guidance that HCCs membership should ensure strategic, comprehensive  21 
coverage of their communities gaps in preparedness and response 
Continue to work with CMS to help health care entities comply with the CMS emergency  21 
preparedness CoPs  
Identify ways to incentivize core member participation in HCCs   21 
Clarify to HPP awardees the flexibility available in meeting Cooperative Agreement  22 
requirements 
AGENCY COMMENTS AND OIG RESPONSE  23 
APPENDICES  24 
A: Summary of ASPRs Capabilities Document and Corresponding Requirements From the  24 
2017 Cooperative Agreement  
B: Related OIG Work  25 
C: Detailed Methodology  26 
D: Additional Ancillary Member Types Included in HCC Membership Lists   29 
E: Excerpts of Unclear 2017 Cooperative Agreement Requirements and Guidance Regarding  31 
HCC Membership 
F:  Agency Comments  32 
ACKNOWLEDGMENTS  34 
 
Selected Health Care Coalitions Increased Involvement in Whole Community Preparedness But Face Developmental Challenges 
Following New Requirements in 2017 
OEI-04-18-00080      BACKGROUND 
Objectives 
1.  To determine the extent to which selected health care coalitions 
(HCCs) expanded membership to include diverse community and 
health care entities to prepare for whole community emergency 
response.  
2.  To determine HCC benefits and challenges coordinating with 
members to prepare for whole community emergency response.  
3.  To identify the extent to which the requirements of and guidance 
for the Hospital Preparedness Program (HPP)administered by 
the Office of the Assistant Secretary for Preparedness and 
Responsefacilitate the ability of HCCs and awardees to prepare 
for whole community emergency response.  
Rationale for this  Public health emergencies, such as hurricanes, call to action diverse 
community and health care entities, to include law enforcement, public 
Study   
health agencies, and health care organizations.  Based on past experience, 
these entities do not always coordinate well and often have different 
community and organizational goals.   
For example, in September 2017, Hurricane Irma left a swath of devastation 
from the U.S. Virgin Islands and northern Puerto Rico to the Florida Keys 
and central Florida.  Tampa Bay health and medical emergency responders 
stated that their coordination with home health agencies, nursing homes, 
and assisted living facilities before the hurricane had been inadequate.1  
Specifically, their emergency response plans underestimated the number of 
patients who would evacuate from these facilities and seek care at hospitals 
or special-needs shelters during the storm.  As a result, hospitals and 
shelters lacked enough supplies (e.g., oxygen tanks and regulators) to care 
for these patients.   
   
Selected Health Care Coalitions Increased Involvement in Whole Community Preparedness But Face Developmental Challenges 
Following New Requirements in 2017 
OEI-04-18-00080    1 
  ASPRs Hospital  The United States has been funding efforts to lessen the effects of public 
health emergencies since the enactment of the Public Health Security and 
Preparedness 
Bioterrorism Preparedness and Response Act of 2002.  The U.S. Department 
Program 
of Health and Human Services Office of the Assistant Secretary for 
Preparedness and Response (ASPR) is in charge of the medical and public-
health aspects of U.S. preparedness, response, and recovery.  ASPR oversees 
the HPP, which is a key Federal funding source of readiness for regional 
health care systems.2,3 
The HPP does not fund HCCs directly.  Instead, the HPP funds HCCs 
through cooperative agreements with State, territorial, metropolitan, and 
Freely Associated States government organizations (hereinafter referred to 
as HPP awardees) to promote community coordination.4  For example, 
HCCs provide benefits (networking, training, etc.) to incentivize these 
entities to work together voluntarily to prepare for and coordinate whole 
community public health or medical emergency responses.   
Since 2002, the HPP has funded approximately $5.9 billion to HPP awardees 
to build health care system preparedness and response capacity.  As of the 
project cycle that began in July 2017, ASPR funded approximately 476 HCCs 
through 62 HPP awardees.5  Cooperative agreement funding to support 
HCCs was $231.5 million in the 2019 budget period.6 
 
HCC Purpose and  Over time, the HPPs recipients and requirements have changed.7  
Specifically, starting in 2002, the HPP funded individual hospitals to 
Membership 
purchase equipment (e.g., ventilators, pharmaceutical caches).  From 2012 
through 2016, the HPP funded awardees to develop health care system 
capabilities in their jurisdictions.  During this project period, HPP awardees 
had the choice to fund individual hospitals for preparedness activities, fund 
a coalition of hospitals and other emergency responders with a role in 
medical surge (i.e., fund an HCC), or fund both. 
With the 20172022 Hospital Preparedness Program (HPP)Public Health 
Emergency Preparedness (PHEP) Cooperative Agreement (hereinafter 
referred to as the 2017 Cooperative Agreement), the HPP began requiring 
awardees to use all HPP funding to develop, mature, and operationalize 
HCCs for whole community emergency response.  In the 2017 Cooperative 
Agreement, the HPP temporarily permits awardees to provide some direct 
funding to individual health care entities for regional preparedness efforts if 
they previously have done so.8  However, as HPP awardees gradually 
reallocate funding to the HCCs, these individual health care entities will work 
with the HCCs to receive HPP funding for projects that ensure regional 
coordination and collaboration.9  The Hospital Preparedness Program 
Cooperative Agreement that went into effect in July 2019 (hereinafter 
Selected Health Care Coalitions Increased Involvement in Whole Community Preparedness But Face Developmental Challenges 
Following New Requirements in 2017 
OEI-04-18-00080    2 
  referred to as the 2019 Cooperative Agreement) reiterates that HPP 
awardees should provide a greater percentage of their total award to HCCs 
each year over the 5-year project period.10  
According to the 2017 Cooperative Agreement, HCCs coordinate and 
incentivize entities to work together to prepare for a whole community 
emergency response that impacts the publics health.11, 12, 13  Such 
emergencies include hurricanes and flooding that requires alternative 
locations for medical services for affected citizens. 
HCCs are member-led and are composed of health and other response 
entities that voluntarily work together to coordinate an emergency 
response.  HCC members prepare for a response through strategic 
planning, health care system preparedness and response gap identification, 
operational planning and response, information-sharing, and resource 
coordination and management.  HCCs also serve as the coordinating entity 
between individual health care entities and jurisdictional incident 
management during whole community emergency responses.14     
The 2017 Cooperative Agreement requires that each HCC include, at 
a minimum, four types of health care and emergency response entities, 
which ASPR has identified as being a core part of whole community 
emergency response (hereinafter referred to as core members).  The 
inclusion of core members ensures that HCCs have members with the 
expertise and authority necessary to adequately carry out HCC 
responsibilities.  The four types of core members are:  
(1) hospitals;15 
(2) public health agencies; 
(3) emergency medical services;16 and 
(4) emergency management organizations. 
See Exhibit 1 for examples of core members roles in whole community 
emergency response. 
 
 
 
 
 
 
 
Selected Health Care Coalitions Increased Involvement in Whole Community Preparedness But Face Developmental Challenges 
Following New Requirements in 2017 
OEI-04-18-00080    3 
   
 
Exhibit 1:  Core members have different but complementary roles in 
 local emergency response 
 
Emergency Medical  Emergency 
Hospitals  Public Health 
 
Services  Management 
 
 
   
 
 
 
 
   
 
 
 
 
Source:  HHS, Medical Surge Capacity and Capability: A Management System for Integrating Medical and Health 
Resources During Large Scale Emergencies, September 2007.  Contract Number 233 03 0028.  Accessed at 
https://www.phe.gov/Preparedness/planning/mscc/handbook/Documents/mscc080626.pdf on May 24, 2018. 
 
Additionally, the 2017 Cooperative Agreement requires HCCs to diversify 
membership beyond the four core member types.  Specifically, each HCC 
must collaborate with diverse community and health care entities to ensure 
that it has the necessary resources for a successful whole community 
emergency response.  According to ASPR officials, in addition to admitting 
core members, HCCs are free to admit any other entity type as a member.  
These non-core HCC members are hereinafter referred to as ancillary 
members.  Although there is no formal requirement for HCCs to use the 
jurisdictional health care system preparedness and response risks and gaps 
identified via the HPP-required Hazard Vulnerability Assessment to inform 
their membership, ASPR officials have stated that HCCs could do so. 
ASPRs document 20172022 Health Care Preparedness and Response 
Capabilities (hereinafter referred to as ASPRs Capabilities Document) 
states that HCCs should include enough members to ensure adequate 
resources but also notes that too many members may make the HCC 
unmanageable.  ASPRs Capabilities Document also lists other health care 
Selected Health Care Coalitions Increased Involvement in Whole Community Preparedness But Face Developmental Challenges 
Following New Requirements in 2017 
OEI-04-18-00080    4 
  entities as possible ancillary HCC member types.  These entities include 
dialysis centers, behavioral health agencies, home health agencies, 
pharmacies, and blood banks.17  Additionally, depending on community 
needs, any community entity with a stake in health care preparedness may 
join an HCC.  For example, a rental car company willing to supply patient 
transport may be an appropriate ancillary member for an HCC in a 
community that has identified limited ambulance service as a response gap.  
See Exhibit 2 for ASPRs suggested HCC membership structure.  
 
Exhibit 2: HCC membership should include community and health 
care entities that are most important to a communitys ability to 
prepare for response 
Community and Health Care Entities
 
HCC Members 
Many community and 
Mandatory   Optional  
health care entities have 
 
Core Members  Ancillary Members 
an interest in health 
Community and health care  Community and health care  care preparedness.  
entities that ASPR has  entities that HCC assessments  Although all entities 
determined are critical to all  have determined are also  should understand 
communities ability to prepare  critical to the communitys  emergency response 
for a whole community  ability to prepare for a whole  procedures in their 
emergency response.  community emergency  community, not all 
  response.   entities are critical for 
i.e., hospitals, public health,  planning and 
e.g., long-term-care facilities, 
emergency medical services,  coordinating the 
outpatient clinics, blood banks  
emergency management  communitys 
emergency response. 
Source: OIG analysis of 2017 Cooperative Agreement and discussions with ASPR officials, 2019. 
 
To manage the number of members in an HCC, and to keep the HCCs 
content and activities relevant to members, ASPRs Capabilities Document 
also recommends that an HCC form a committee structure.  For example, if 
an HCC has multiple entities of the same type, the HCC may work with 
those entities to form a committee.  A committee representative may serve 
as the HCC member and act as a liaison between the HCC and the other 
entities of the same type.  If an HCC uses this committee structure, each 
community and health care entity does not have to be an HCC member to 
become integrated into whole community emergency response plans.   
 
Oversight of HCCs   ASPR does not directly oversee HCCs or monitor individual HCCs progress 
toward whole community emergency response.  Instead, ASPR oversees the 
Selected Health Care Coalitions Increased Involvement in Whole Community Preparedness But Face Developmental Challenges 
Following New Requirements in 2017 
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  HPP awardees, who in turn oversee the HCCs and report on HCC progress 
and performance to ASPR.  HPP awardees interpret requirements in the 
Cooperative Agreement and develop work plans for how they and their 
HCCs will meet the Cooperative Agreement requirements.  According to 
ASPR officials, HCCs and HPP awardees have flexibility in how they meet 
Cooperative Agreement requirements.  If an HCC or HPP awardee has 
difficulty in developing a plan to meet a Cooperative Agreement 
requirement, ASPR will provide additional guidance and negotiate 
alternative ways to meet the requirement.  
 
ASPR Guidance to  To help HCCs and other health care entities in their planning, ASPRs 
Capabilities Document includes aspirational goals, or aspirational 
HCCs and HPP 
capabilities, for health care system readiness.18  According to ASPR, because 
Awardees  
these capabilities are aspirational, HCCs and HPP awardees should not 
expect to achieve them solely through HPP funding.  However, the 
Cooperative Agreement requirements are intended to help push HCCs 
toward these aspirational goals.  ASPR also identifies activities that HCCs 
and health care organizations can perform (but are not required to 
perform)to help achieve each capability.  See Appendix A for a summary 
of the four capabilities related to health care preparedness and response 
and an abbreviated list of 2017 Cooperative Agreement requirements 
associated with each capability.   
Additionally, ASPR provides several other types of guidance both to HCCs 
and HPP awardees regarding how to prepare for a whole community 
response and how HCCs can meet the Cooperative Agreement 
requirements.  Through ASPRs Technical Resources, Assistance Center, and 
Information Exchange (TRACIE) website, HCCs and HPP awardees have 
access to academic literature, exercise templates, facility-specific emergency 
plans, and other technical assistance.  ASPR also conducts periodic 
teleconferences and webinars and sends out weekly newsletters about 
ASPRs HPP activities.  Further, ASPRs regional Field Project Officers provide 
tailored technical assistance and general guidance to HCCs.  For example, 
Field Project Officers can offer HCCs guidance on how to meet Cooperative 
Agreement requirements or negotiate alternative ways to meet these 
requirements.  Additionally, Field Project Officers conduct site visits of HPP 
awardees and HCCs.  During site visits, they monitor and evaluate (1) HPP 
awardee progress in meeting work plan priorities and (2) HPP awardee and 
HCC activities to meet Cooperative Agreement requirements.       
ASPR also provides guidance to HCC members on how to meet new 
Centers for Medicare & Medicaid Services (CMS) emergency preparedness 
Conditions of Participation (CoPs).  According to ASPR officials, ASPR has 
Selected Health Care Coalitions Increased Involvement in Whole Community Preparedness But Face Developmental Challenges 
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  collaborated with CMS to develop resources to support health care entities 
in complying with the emergency preparedness CoPs.  These resources are 
available to HCCs and their members on the ASPR TRACIE website.  ASPR 
also works with national professional associations to identify and distribute 
resources to health care entities and to HCCs.  Additionally, HPP has 
collaborated with the Federal Emergency Management Agencys (FEMAs) 
Center for Domestic Preparedness to develop trainings to support health 
care entities that are subject to the CMS emergency preparedness CoPs. 
 
Other Federal  Other Federal agencies have emergency preparedness requirements or 
provide emergency preparedness funding that impact HCCs.  Three key 
Emergency 
agencies are CMS, FEMA, and the Centers for Disease Control and 
Preparedness 
Prevention (CDC).  Additional Federal agencies impact HCCs, but to a lesser 
Activities That  extent. 
Impact HCCs 
Centers for Medicare & Medicaid Services.  In November 2016, new CMS 
regulations to include emergency preparedness requirements as CoPs for all 
Medicare- and Medicaid-reimbursed entities went into effect.19  These 
entities include hospitals and 16 other types of health care entities.20  
Affected entities must have met all requirements 1 year after the effective 
date (i.e., by November 15, 2017).  Specifically, these entities must now 
develop facility-based emergency programs that address how the facility 
would coordinate with other health care facilitiesas well as the whole 
communityduring an emergency or disaster.  Depending on the type of 
services they provide, most of these entities must also train their staff in 
emergency preparedness principles and exercise their emergency plans in 
conjunction with other community groups.  CMSs emergency preparedness 
CoPs require these entities to coordinate with emergency management 
agencies.  The emergency preparedness CoPs also suggest that HCC 
membership may help these entities meet these new requirements. 
On February 1, 2019, CMS added emerging infectious diseases to the current 
definition of an all-hazards approach.  CMS determined that entities should 
consider preparedness and infection prevention within their all-hazards 
approach, which includes both natural and man-made disasters.21 
Federal Emergency Management Agency.  FEMAs Emergency 
Management Performance Grant Program and Homeland Security Grant 
Program fund State and local emergency management organizations.  
According to ASPR officials, the HPP and the Homeland Security Grant 
Program coordinate to ensure that their requirements include common 
language.  The Homeland Security Grant Program allows (but does not 
require) emergency management organizations to work with HCCs to 
improve preparedness.  Additionally, FEMA funds the Urban Area Security 
Selected Health Care Coalitions Increased Involvement in Whole Community Preparedness But Face Developmental Challenges 
Following New Requirements in 2017 
OEI-04-18-00080    7 
  Initiative.  This grant program is one of three that make up the Homeland 
Security Grant Program.  The Homeland Security Grant Program supports 
FEMAs core capabilities across the five mission areas of prevention, 
protection, mitigation, response, and recovery.22 
Centers for Disease Control and Prevention.  CDC monitors and responds 
to public health emergencies; conducts research; and provides guidance to 
health care providers, government entities, and the public.23  CDCs Public 
Health Emergency Preparedness (PHEP) Cooperative Agreement supports 
the emergency preparedness efforts of State and local public health 
agencies.  Since the 2012 project cycle, CDC and ASPR have aligned PHEP 
and HPP capabilities and established joint goals and activities to improve 
preparedness.  For example, in response to the Ebola outbreak in 2014, CDC 
provided additional PHEP funding to States and localities;24 stockpiled 
protective equipment for health care workers;25 and revised its infection 
control guidance for health care providers, communities, and other public 
entities.26 
Other Federal Agencies With Areas of Responsibility Related to HCCs.  At 
least two other Federal agencies also have programs that affect HCCs and 
their members.  These agencies include: 
  The Health Resources and Services Administration (HRSA): HRSAs 
Emergency Medical Services for Children State Partnership Program 
provides funding to State governments and accredited schools of 
medicine.  The funding supports demonstration projects to expand 
and improve State emergency medical services for children who 
need treatment for trauma or critical care.27   
  The National Highway Traffic Safety Administration (NHTSA):  
NHTSAs Office of Emergency Medical Services coordinates the 
national emergency medical services system and co-coordinates the 
national 911 system through research and projects.28  The Office of 
Emergency Medical Services is also part of a national focus on 
integrating emergency medical services into planning and 
preparedness initiatives.29  
 
Related OIG Work  Several OIG reports have assessed health care entities emergency 
preparedness and response efforts.  These include hospital preparedness 
after the 2014 Ebola outbreak, nursing home preparedness and response 
during disasters from 2007-2010, and State and local preparedness for 
pandemic influenza in 2008.  OIG work has resulted in requirements for 
better emergency planning and better coordination between health care 
providers.  See Appendix B for more information on past OIG work.   
Selected Health Care Coalitions Increased Involvement in Whole Community Preparedness But Face Developmental Challenges 
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Methodology    We selected a purposive sample of 20 HCCs from the total 476 HCCs at the 
time of our data collection.  We also selected the 20 HPP awardees 
corresponding to these HCCs.  These HCCs and HPP awardees all received 
funding as of the project cycle beginning July 2017.  We conducted 
structured interviews, administered surveys, and collected documentation 
from each HCC and HPP awardee from November 2018 to January 2019.  To 
ensure variation when selecting our sample, we selected at least 1 HCC from 
each of the 10 HHS regions and considered variations in population size and 
number of disasters recorded in the FEMA Disaster Database in 2017.   
Through the interviews, we obtained qualitative data and organized the 
data on the basis of common themes.  We also analyzed survey data and 
reviewed documentation, such as HCC membership lists, Cooperative 
Agreement requirements, and ASPR guidance (e.g., ASPRs Capabilities 
Document).  See Appendix C for more details on our methodology.  
This is not a review of the Federal, State, or local government response to 
the COVID-19 public health emergency.  
   
Limitations  Because our sample of HCCs and HPP awardees is purposive, results apply 
only to the 20 HCCs and 20 HPP awardees in our review.  Responses cannot 
be generalized to all HCCs or HPP awardees receiving HPP funds.    
Additionally, we selected the 20 HCCs on the basis of geographic 
distribution, size, and number of recent disasters.  We did not consider 
other factors, such as how long each HCC had functioned as an HCC, when 
selecting our sample.          
We requested supporting documentation that included membership lists.  
We did not independently verify the accuracy or completeness of this 
documentation.  Additionally, we could not determine from the 
membership lists provided each HCC members level of involvement with 
that HCC.   
 
Standards  We conducted this study in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors General on 
Integrity and Efficiency. 
   
Selected Health Care Coalitions Increased Involvement in Whole Community Preparedness But Face Developmental Challenges 
Following New Requirements in 2017 
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  FINDINGS 
Nearly all 20  Since ASPRs 2017 Cooperative Agreement requirements and CMS 
emergency preparedness CoPs went into effect, nearly all 20 HCCs in our 
selected HCCs 
review have expanded their membership to include new, more diverse 
reported expanding 
entity types.  Further, all selected HCCs reported that their members take 
their membership  part in HCC activities that benefit preparedness for a whole community 
and that members  emergency response.    
participate in 
Most of the 20 HCCs have expanded their membership, primarily 
beneficial 
through an increase in new diverse types of entities 
preparedness  Because of new ASPR 2017 Cooperative Agreement requirements and CMS 
emergency preparedness CoPs, 19 of the 20 HCCs in our review expanded 
activities 
their membership to include more types of entities than they had before 
2017.  The remaining HCC reported no expanded membership because it 
already had core and ancillary representation from all necessary community 
and health care entities before the HPP core member requirements became 
effective.  
Six HCCs that expanded membership reported increases in one or more of 
the four types of core members (hospitals, public health agencies, 
emergency medical services, and emergency management organizations).  
Most HCCs already had core representation from these four entity types 
before the HPP required their membership.  Further, our review of HCC 
membership lists confirmed that all 20 HCCs in our sample had 
representation from all four types of core members.    
Prior to this new guidance  Of the HCCs in our review that reported expanded membership, all 
[to diversify membership  reported increases in ancillary members (e.g., home health agencies, 
beyond core members], we  long-term-care facilities).  According to most (12 of 19) of these HCCs, this 
were specifically a hospital 
expansion was due to the CMS emergency preparedness CoPs.  These 
and Emergency Medical 
requirements prompted entities that were subject to these CoPs to seek out 
Services committee.  Now, 
membership in HCCs to help meet several of the CoPs.  For example, HCCs 
we have extended to home 
reported offering training opportunities (9 HCCs) and community-based 
health, hospice, dialysis, 
exercises, drills, or tabletop exercises (10 HCCs) as activities that helped 
long-term care, and 
community life programs.    entities to meet CMS emergency preparedness CoPs.   
 HCC Representative  Our review of HCC membership lists showed that all 20 selected HCCs 
include ancillary members from diverse entity types.  All but one HCC 
membership list included at least one type of ancillary member subject to 
CMS emergency preparedness CoPs.  All HCC membership lists also 
included at least one other type of ancillary member not subject to CMS 
emergency preparedness CoPs.  See Exhibit 3 for a list of the most 
Selected Health Care Coalitions Increased Involvement in Whole Community Preparedness But Face Developmental Challenges 
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  commonly reported types of ancillary members and Appendix D for a list of 
additional reported type of ancillary members. 
Exhibit 3:  HCCs reported a variety of ancillary member types on their 
membership lists 
Ancillary members subject to CMS emergency  Number of HCCs 
preparedness CoPs  reporting member 
type 
Home health agencies  17 
Long-term-care facilities  16  
Outpatient clinics (e.g., clinics, rehabilitation agencies, and  14 
public health agencies as providers of outpatient physical 
therapy and speech-language pathology services or 
Comprehensive Outpatient Rehabilitation Facilities) *  
Hospice   13 
Federally Qualified Health Centers   11 
Other ancillary members not subject to CMS   
emergency preparedness CoPs  
Fire departments   14 
Assisted living facilities   11 
Pediatric centers  11 
Source: OIG analysis of membership lists for 20 selected HCCs, 2019. 
* The membership lists that we analyzed did not designate which outpatient facilities were certified by 
CMS as Comprehensive Outpatient Rehabilitation Facilities.  Because we could not distinguish 
Comprehensive Outpatient Rehabilitation Facilities from other types of outpatient clinics, we created 
a general category for outpatient clinics.   
 
All HCCs reported that their members participate in beneficial 
preparedness activities offered by the HCC 
Of the 20 HCCs in our review, all reported that both their new members and 
their experienced members participate in HCC-offered activities that benefit 
whole community preparedness.  See Exhibit 4 on the next page for a list of 
the activities that HCCs reported.   
 
 
   
Selected Health Care Coalitions Increased Involvement in Whole Community Preparedness But Face Developmental Challenges 
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  Exhibit 4:  HCCs reported a variety of beneficial preparedness 
activities in which their members participate 
HCC preparedness activity  Number of HCCs 
reporting activity 
Information sharing  11  
Community-based exercises, drills, tabletops  10 
Developmental activities (e.g., training and education)  9 
Networking and relationship building  7 
Resource sharing (e.g., staff and supplies)  4 
Coordination   3 
Situational awareness  2 
Source: OIG analysis of HCC interview responses, 2019.  
 
New ancillary members have benefited from participating in HCC activities 
with experienced core members.  Specifically, more than half of the HCCs in 
Some of the new facilities  our sample11 of 20reported that new ancillary members with previously 
have a lot of transportation  limited experience are now learning about basic emergency concepts from 
and are willing to help  experienced core members.  For example, experienced core members 
evacuate when they are not 
helped ancillary members develop coordinated emergency-operations 
themselves evacuating.  
plans and exercise these plans.   
The Surgery Centers have 
also offered up the use of  Experienced core members have also benefited from participating in HCC 
their space if someone can  activities with new ancillary members.  Specifically, 12 HCCs reported that 
get a generator there.    increased coordination between new ancillary members and experienced 
-  HCC Representative  core members helped their communities better prepare for and respond to 
an emergency.  Seven of these HCCs reported that new ancillary members 
benefited their community preparedness by pointing out gaps in their 
respective health care systems preparedness and response that 
experienced core members had not previously considered.  Additionally, 
some HCCs (5 of 12) reported that new ancillary members provided new 
perspectives, expertise, and capabilities that benefited the HCCs core 
members.  This included identifying and offering resources that the core 
members had not previously thought of or to which the HCC had not 
previously had access via its members.  These resources include staff from 
private clinics and transportation from companies such as limousine 
services.  
  
 
 
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However, expanded  Although HCCs reported that expanded membership has benefits, they 
reported that this growth also presents challenges.  The reported 
membership also 
membership challenges appear to be from an influx of new ancillary 
presents challenges.  
member types resulting from HCCs expanding in ways that were not 
It has not always  strategic.  That is, most (18 of 19) HCCs reported accepting all entity 
requests to join their HCC without regard to the HCCs identified community 
been done 
needs and health care systems gaps in preparedness and response.  As a 
strategically and has 
result, HCCs have many new ancillary members with significant training and 
caused some HCCs 
education needs and little knowledge and experience in emergency 
to concentrate  preparedness.  Therefore, more than half (12) of HCCs reported 
concentrating their limited resources on addressing these new members 
limited resources on 
needs.  Some of these HCCs (4) reported that this concentration of limited 
new members. 
resources on new member needs comes at the expense of other HCC 
priorities and goals. 
  
HCC expansion is not always strategic  
Most HCCs did not strategically determine which entities they should accept 
as ancillary members.  Of the 19 HCCs that reported their membership is 
expanding, most (16) reported that they admit any entity requesting 
membership.  Two additional HCCs specified that they admit as members 
We will accept any 
any entity subject to CMS emergency preparedness CoPs.  These 18 HCCs 
member.  We welcome 
are not strategically growing their membership.  Specifically, they do not 
anyone who wants to be in 
the HCC and engage in  prioritize new members based on their communities health care systems 
preparedness.     gaps in preparedness and response, as suggested by ASPR officials.   
-  HCC Representative  Eight HCCs indicated that they use assessments of their communities health 
care systems gaps in preparedness and response to help guide their 
membership, at least to some extent.  Specifically, four HCCs reported that 
they use members experiences with the health care system to assess gaps 
in their membership lists.  However, only one of these four HCCs reported 
using identified gaps to prioritize HCC members.  While the remaining three 
HCCs ensured that identified membership gaps were filled, they also 
allowed any other ancillary entity type requesting membership to become 
an HCC member.  Of the remaining four, two HCCs reported using the 
Hazard Vulnerability Assessment and two HCCs reported using other formal 
assessments (i.e., public health needs assessment and gap analysis) to 
determine which entities were most important to include as members.30  
However, none of these HCCs used assessment-identified membership gaps 
to prioritize members and strategically grow their HCC.  Instead, these four 
HCCs ensured that assessment-identified membership gaps were filled while 
also allowing any other ancillary entity type to become an HCC member.      
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  Four others of the 19 HCCs that reported membership expansion reported 
that they implemented a committee structure as a strategy for integrating 
their new ancillary members into the HCC.  Two of these four HCCs were 
among the five that use assessments to identify membership gaps.  
However, all four allowed any entity type to become a member and used 
a committee structure to integrate them into the HCC.31  
Many HCCs concentrate their limited resources on the needs of new 
members 
More than half (14) of the 20 HCCs in our sample reported that they spend 
a substantial part of their limited resources training new members to have 
the skills necessary to be contributing members.  Additionally, six HCCs 
noted that frequent turnover at some ancillary member facilities means that 
training new, inexperienced members is a continuous and 
resource-intensive process.  Nine HCCs reported that they have struggled to 
Because of the CMS rules, a 
integrate new ancillary members and function as a unified HCC that focuses 
lot of new people have 
on the same goals.  Three of these nine HCCs specifically reported concerns 
come on board, but the 
that the time dedicated to helping new members learn the basics of health 
facilities send new people 
who do not know anything  care preparedness is changing the scope of their HCCs work.  Specifically, 
about emergency  helping new members with their needs causes the HCC to focus less on 
preparedness.  It takes a  planning for whole community emergency response coordination, 
long time to get everyone  continuity of health care service delivery, and medical surge than it did 
to have the exercises they 
before its membership expanded.    
 need to be compliant with 
CMS or other accreditation  HCCs also reported spending considerable resources on activities to help 
agencies.    members meet the CMS emergency preparedness CoPs.  ASPRs 2017 
Cooperative Agreement requirements do not allow HCCs to provide 
-  HCC Representative 
one-on-one support to HCC members to help them meet the CMS 
emergency preparedness CoPs, and no HCC in our sample reported 
violating this prohibition.32  However, 18 of the 20 HCCs in our review 
reported using HPP resources to conduct group activities to help HCC 
members meet the CMS emergency preparedness CoPs.  These activities 
include providing training to help members prepare for surveyor inspections 
and conducting entity-type specific exercises.   
 
HCCs also face  While the CMS emergency preparedness CoPs have incentivized new 
ancillary member participation, most HCCs (18) expressed concerns about 
challenges in 
their ability to incentivize core members participation in HCC activities.  
incentivizing core 
Despite some HCCs reporting benefits of expanding membership to diverse 
members  ancillary members, 7 of these 18 HCCs expressed general concerns that the 
HCCs focus on integrating new ancillary members has decreased the 
participation 
perceived value of the HCCs for some experienced core members.  This 
  perception has contributed to a decrease in core member participation in 
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  some HCCs.  Specifically, five of these seven HCCs reported that some of 
their core members are no longer participating in HCC activities or they 
participate less often than they once did.      
HCCs most often reported specific challenges in incentivizing hospitals (12), 
followed by emergency medical services (11) and emergency management 
We have to accommodate 
the various levels of expertise  organizations (11).  No HCCs in our review reported issues incentivizing the 
and needs.  Having the huge  fourth core member typepublic health agencies.  The close association 
number of ancillary members  between CDCs PHEP Cooperative Agreement and the HPP likely facilitates 
come in has, frankly,  public health participation in HCCs because HCC activities help public health 
changed the content enough  organizations meet some PHEP requirements.  
that we are losing some of 
our core partners.    Challenges in incentivizing hospitals include competitor risk, 
- HCC Representative  competing priorities, HCCs lack of hospital-focused content, and 
decreased financial compensation  
For the 12 HCCs that cited challenges in incentivizing hospitals, 4 HCCs 
reported that hospitals are hesitant to participate fully in HCC activities with 
competitor hospitals.  As one HCC explained, some hospitals feel that the 
I have sensed a bit of a back 
risk of sharing their emergency plans with competitors is not worth the 
stepping on the part of 
value they get from the HCC when the likelihood of an emergency response 
hospital leadership or the 
is low.  Four HCCs explained hospitals decreasing participation in the HCC 
hospital emergency 
stemmed from their perception that HCCs lack meaningful hospital-focused 
managers.  They are not 
seeing the benefit to them.    content.  One of these four HCCs attributed this to the HCCs increased 
- HCC Representative  focus on the needs of ancillary members.  Three of the twelve HCCs partly 
attributed the many other responsibilities that fall on hospitals for their 
waning participation.  Further, three reported that the challenge was 
because hospitals are financially driven, and HCC participation can no 
longer result in direct financial assistance.   
Challenges in incentivizing emergency medical services include 
competing priorities and limited time and resources   
Eleven HCCs reported challenges in incentivizing emergency medical 
The biggest challenge is with  services.  Six of these eleven reported that the challenge stemmed not from 
emergency medical services.  
a lack of a desire to participate in HCC activities, but from emergency 
Most emergency medical 
medical services inability to prioritize HCC activities given their other 
technicians in our State are 
professional priorities.  Two of these six HCCs reported that most 
volunteers.  It does not make 
emergency medical services in their State are volunteer organizations.  
sense for them to take time 
Therefore, they have limited time or resources available for HCC activities.  
away from their paid job to 
Four HCCs questioned the value that they could provide to emergency 
attend a meeting for their 
volunteer job.    medical services.  Five HCCs provided other reasons for challenges with 
emergency medical services, including the inability to compensate 
- HCC Representative 
emergency medical services for their time and the misalignment of 
emergency medical services jurisdictional boundaries with HCC boundaries.   
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  Some (5) of the eleven HCCs who reported challenges in incentivizing 
emergency medical services stated that they have strategized ways to better 
coordinate with emergency medical services other than asking them to 
participate in HCC activities.  For example, three HCCs tried to enhance 
coordination with emergency medical services by sending 
HCC representatives to meetings that emergency medical services members 
already attended instead of asking them to come to separate HCC 
meetings.  One of the HCCs that used this strategy reported some success 
in developing a strong line of communication between emergency medical 
services and the HCC.    
Emergency management is a  Challenges in incentivizing emergency management organizations 
struggle because we need to  include competing priorities and perceived lack of HCC value  
make it about them, too.  
Eleven HCCs reported challenges in incentivizing emergency management 
And sometimes, if it is too 
organizations.  Six HCCs reported that obtaining and maintaining 
health-centric, they just do 
participation from emergency management organizations was challenging 
not show up.  
given responsibilities associated with their full-time jobs and other 
- HCC Representative 
emergency management duties outside of the HCC.  Four others of these 
eleven HCCs stated that they were struggling to obtain and maintain 
participation because emergency management organizations did not 
appear to find value in HCC activities.  HCCs reported that this is partly 
because emergency management organizations see HCC activities as 
focused solely on health care preparedness rather than general emergency 
management.  One of these four HCCs reported challenges maintaining 
emergency management organization participation stemmed from the 
HCCs focus on ancillary members.  This focus, the HCC explained, has 
resulted in a lack of content that is meaningful to emergency management 
organizations.   
  
ASPR guidance is  Overall, HCCs and HPP awardees generally found ASPR guidance useful in 
preparing for a whole community emergency response.  However, HPP 
generally beneficial; 
awardees interpreted membership requirements in different ways, indicating 
however, some 
that HPP awardees find these requirements unclear.  Further, based on our 
unclear 2017  interviews with ASPR, HCCs, and HPP awardees, as well as our review of the 
Cooperative  2017 Cooperative Agreement requirements and guidance, we found that 
some 2017 Cooperative Agreement requirements are not clear.    
Agreement 
Additionally, although ASPR described flexibility in cooperative agreement 
requirements and 
requirements, several HPP awardees reported challenges with other 
guidance contribute prescriptive requirements.  This lack of clarity contributes to awardee 
challenges in guiding HCC strategic growth and in developing valuable 
to HCC 
HCCs that incentivize core members participation.    
preparedness 
challenges  
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HCCs and HPP awardees generally found ASPR guidance helpful   
HCCs (19) and HPP awardees (15) found a variety of ASPR guidance helpful 
in preparing for a whole community response.  The guidance they reported 
as helpful is listed in Exhibit 5 below.   
 
Exhibit 5:  HCCs and HPP awardees found a variety of ASPR guidance 
helpful in preparing for whole community response 
Type of guidance  HCCs   HPP Awardees  Total  
(n=20)  (n=20)   (n=40) 
       
ASPR Capabilities Document  18   14   32  
ASPR TRACIE technical  16   14  30 
resources 
ASPR webinars  14   12   26  
Field Project Officers  9   13   22 
ASPR TRACIE Assistance  14   5   19  
Center 
HHSs 2009 Medical Surge  11   7   18  
Capacity and Capability 
Manual 
ASPR TRACIE Information  10   7   17  
Exchange 
 Source: OIG analysis of data from survey of HCCs and HPP awardees, 2019. 
 
Some 2017 Cooperative Agreement requirements and guidance 
regarding HCC membership are not clear, which contributes to 
HCCs lack of strategic growth   
Unclear 2017 Cooperative Agreement requirements and guidance 
contributed to some HPP awardees not directing their HCCs to use 
assessments, such as Hazard Vulnerability Assessments, to strategically 
grow.  According to ASPR officials, HCCs should decide which entities to 
include as ancillary members based on assessments that identify 
jurisdictional health care systems gaps in preparedness and response.  
However, neither the 2017 Cooperative Agreement requirements nor the 
guidance that we reviewed explicitly convey this expectation.  This lack of 
clarity in the membership requirements and guidance contributed to HPP 
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  awardees different interpretations of how they should direct or guide their 
HCCs membership growth.  Only one HPP awardee in our review reported 
that it directed its HCCs to grow strategically using assessments of the 
health care systems gaps in preparedness and response.33  The remaining 
HPP awardees reported no strategy for guiding HCC membership decisions 
(8 HPP awardees), leaving membership decisions up to experienced HCC 
members (7 HPP awardees), encouraging or allowing their HCCs to accept 
any entity that requests HCC membership, or any entity listed as a possible 
member in ASPRs Capabilities Document or HPP annual reporting guidance 
(3 HPP awardees); or not knowing how its HCCs determined membership 
(1 HPP awardee).34   
In addition, we found some potentially conflicting excerpts in the 2017 
Cooperative Agreement and the ASPR Capabilities Document regarding 
The whole world has to be 
invited to the HCC.  I think  HCC membership.  These potentially conflicting excerpts likely contributed 
ASPR is really getting too  to HPP awardees perception that ASPR does not recommend using 
far down the road with  assessments to guide strategic membership growth.  For example:  
how they are requiring so 
  The 2017 Cooperative Agreement requirements state that HPP 
many organizations to be 
awardees must ensure that there are no geographic gaps in HCC 
involved.   
coverage and that all interested health care facilities, including 
- HPP Awardee 
independent facilities, are able to join an HCC, if desired.  This 
excerpt implies that ALL health care entities should be HCC 
members.   
  ASPRs Capabilities Document states that HCCs should include 
enough members to ensure adequate resources but that having 
Most HCCs have stuck to 
core four plus maybe  too many members may make the HCC unmanageable.  This 
some ancillary  excerpt implies that NOT ALL health care facilities should be 
membership according to  members of the HCC.   
the broader medical 
The 2019 Cooperative Agreement, effective July 2019, partially addresses this 
system.  HCC membership 
lack of clarity by removing the language stating that HCCs must ensure that 
varies from region to 
all interested health care entities are able to join the HCC.  However, it did 
region.  
not clarify that HCCs should prioritize member types on the basis of 
- HPP Awardee 
an assessment of the health care systems gaps in preparedness and 
response, as ASPR officials told us is recommended.  See Appendix E for a 
table of 2017 Cooperative Agreement requirements and guidance excerpts 
from the 2017 Cooperative Agreement and ASPRs Capabilities Document 
about HCC membership that we found were unclear.    
 
 
 
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  Unclear flexibility in the 2017 Cooperative Agreement requirements 
may contribute to HCC challenges in incentivizing core members 
participation  
Some HPP awardees perception that 2017 Cooperative Agreement 
requirements are prescriptive may lead them to manage, oversee, or guide 
There are a lot of musts in 
the Cooperative Agreement.   HCCs in ways that meet 2017 Cooperative Agreement requirements but that 
If it is not a meaningful  do not create value for core members.  HCC activities must offer enough 
experience, or if members  value that core members are incentivized to participate, as one HPP 
leave meetings saying, "well  awardee reported.  However, more than half of the HPP awardees (14) in 
that was worthless, we are  our review reported that prescriptive 2017 Cooperative Agreement 
going to lose them. 
requirements do not allow them to develop valuable HCCs.  That is, the HPP 
- HPP Awardee  awardees perceived that they could not support HCC activities that 
addressed unique priorities such as those identified as health care system 
preparedness or response gaps.  Further, 8 of the 14 HPP awardees 
reported that prescriptive requirements force HCC members to work on 
activities that check the box but do not advance preparedness and 
response capability in their respective jurisdictions.  For example, one HPP 
We had 7 years of building  awardee reported that the work required for a very detailed budget plan 
these HCCs, and now there  used time that HCC members could have used on preparedness activities.  
are all these musts that 
Further, 4 of the 14 HPP awardees specified that prescriptive 2017 
the HCCs push back on.  
Cooperative Agreement requirements are currently causing core members 
How are they going to keep 
to scale back their participation in HCC activities.   
doing things under 
restrictions?  Do we sacrifice  Although most HPP awardees do not perceive flexibility in the 2017 
the usefulness of the  Cooperative Agreement requirements, ASPR officials reported that there is 
coalitions to meet the  some flexibility in how HCCs and HPP awardees may meet requirements.  
requirements, so we keep 
ASPR officials told us that if an HCC or HPP awardee believes that 
getting money?   
a requirement does not apply to the HCCs or the HPP awardees unique 
- HPP Awardee  situation, the HCC or HPP awardee can work with its Field Project Officer to 
negotiate alternatives that would be more responsive to its needs.  
However, this flexibility is not clearly stated in any of the 2017 Cooperative 
Agreement requirements or guidance documents that we reviewed.   
 
   
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  CONCLUSION AND RECOMMENDATIONS 
The selected HCCs in our review reported increased involvement in whole 
community preparedness following changes to certain facilities 
preparedness activities requirements in 2017.  However, they also reported 
developmental challenges that require continued focus.  
Specifically, HCCs in our review reported that since 2017, they have 
expanded their membership, primarily through the addition of new ancillary 
members seeking to meet CMSs emergency preparedness CoPs.  The HCCs 
also reported that new ancillary members and experienced core members 
now participate together in HCC activities that benefit whole community 
preparedness.  
Although HCCs reported on the benefits of expanded membership, they 
also reported that this expansion presented challenges.  For example, some 
HCCs reported having added new ancillary member types in ways that were 
not strategic.  Specifically, many HCCs admitted all new entities that 
requested to join, regardless of whether the new members filled gaps in 
their communities identified needs for health care system preparedness 
and response.  Further, some HCCs reported concentrating their limited 
resources on conducting group activities to help new ancillary members 
meet the CMS emergency preparedness CoPs.  These activities lessened the 
resources available for other HCC priorities.   
Further, most HCCs also reported challenges in incentivizing core members 
participation.  In some cases, HCCs challenges in incentivizing core 
members were related to the concentration of HCCs resources on new 
ancillary members to the detriment of other preparedness activities.  Most 
HCCs also reported other challenges specific to incentivizing one or more of 
the four types of core members.   
Finally, HCCs and HPP awardees generally found ASPR guidance helpful for 
preparing for a whole community response.  However, some unclear 2017 
Cooperative Agreement requirements and guidance regarding membership 
and lack of clarity about requirement flexibility contributes to the challenges 
that HCCs and their HPP awardees report.  
We did not conduct a review of the Federal, state, or local government 
response to the COVID-19 public health emergency.  
To further improve communities preparedness for a whole community 
emergency response and ensure the benefits of membership expansion 
outweigh the challenges, ASPR should:  
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  Clarify HPP guidance that HCCs membership should ensure 
strategic, comprehensive coverage of their communities gaps 
in preparedness and response  
ASPR should consolidate the most pertinent guidance regarding HCC 
membership and clarify that only core members are required.  Further, ASPR 
should clarify that HCCs should ensure that all other members represent 
entity types necessary for an effective whole community response.  HCCs 
should determine which member types are necessary for an effective whole 
community response using assessments of the health care systems gaps in 
preparedness and response (e.g., Hazard Vulnerability Assessments (HVAs)).  
This clarified ASPR guidance could also include how HCCs may use 
assessments to identify which entities are necessary for an effective whole 
community response.  Additionally, ASPR should also emphasize existing 
ASPR guidance that HCCs may use an ancillary committee structure to 
integrate large groups of similar types of members.   
Continue to work with CMS to help health care entities comply 
with the CMS emergency preparedness CoPs   
ASPR should continue to work with CMS to provide health care entities with 
tools and resources that can help them comply with the CMS emergency 
preparedness CoPs.  This would ensure that the burden does not fall solely 
on the HCC to provide basic emergency preparedness training to ancillary 
members.  This would also allow the HCC to stay focused on whole 
community preparedness.  Specifically, ASPR should continue to collaborate 
with CMS to compile lists of local or virtual training and consultation 
resources to help health care entities comply with the CMS emergency 
preparedness CoPs.  HCCs can, in turn, help community health care entities 
by referring entities to these identified resources rather than providing the 
bulk of new member training themselves.  Additionally, ASPR should 
continue to work with national professional associations to identify and 
distribute resources to health care entities that need help complying with 
the CMS emergency preparedness CoPs.   
Identify ways to incentivize core member participation in HCCs    
ASPR should work with HPP awardees to identify promising practices to 
incentivize core member participation in HCCs.  One approach would be to 
make it easier for core members to participate.  For example, ASPR could 
encourage HCC representatives to attend scheduled professional meetings 
held by core member groups instead of asking core members to attend a 
separate HCC meeting.  Another option would be to make sure that HCCs 
provide value to all members, especially core members.  Toward that end, 
ASPR could critically examine its reporting requirements to determine which 
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  may result in HCC activities that are of less value for some core members, 
and ASPR could eliminate or revise those requirements.   
Clarify to HPP awardees the flexibility available in meeting 
Cooperative Agreement requirements    
ASPR should clarify flexibility in Cooperative Agreement requirements to 
avoid HPP awardees perception of prescriptiveness.  For example, ASPR 
should make HCCs and HPP awardees aware of the option to work with 
their Field Project Officer when HCCs or HPP awardees find that (1) a 
requirement does not apply to their HCCs or (2) fulfilling the requirement 
hinders the HCCs ability to work on issues identified as a priority in 
assessments. 
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  AGENCY COMMENTS AND OIG RESPONSE  
ASPR concurred with all four of our recommendations.  In particular, for our 
first and fourth recommendations, ASPR stated that it may clarify future HPP 
or other guidance to HPP awardees.  For our second recommendation, 
ASPR stated that it will continue to build and leverage ASPRs TRACIE 
collaboration with CMS regarding the emergency preparedness COPs and 
making resources available to HCCs.  ASPR also stated that it will continue 
to work with HPP partners, including national professional associations, to 
provide information on the CMS emergency preparedness CoPs and HPP 
program and policy updates.  Finally, in response to our third 
recommendation, ASPR stated that it will look into core membership trends, 
and leverage forums and meetings with awardees, HCCs, and other health 
care organizations to identify lessons learned regarding core member 
recruitment and participation incentives.   
OIG appreciates ASPRs efforts to address this important issue.  However, 
OIG urges ASPR to more strongly consider taking action to clarify guidance 
to HCCs that membership should ensure strategic, comprehensive coverage 
and to HPP awardees that they have flexibility in meeting Cooperative 
Agreement requirements.  Clarified guidance will reinforce the need for 
HCCs to focus their limited resources on their communities priorities rather 
than on helping certain members to meet CMS emergency preparedness 
COPs that may not create value for core members.  With clarified guidance, 
HCCs can more efficiently and effectively improve their communities 
emergency preparedness and response.  
For the full text of ASPRs comments, see Appendix F.   
 
 
 
 
 
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  APPENDIX A: Summary of ASPRs Capabilities 
Document and Corresponding Requirements 
From the 2017 Cooperative Agreement  
Exhibit A-1: In its document 20172022 Health Care Preparedness and Response Capabilities 
(referred to in this report as ASPRs Capabilities Document), ASPR has aligned aspirational 
capabilities for health care system readiness with the requirements from the 2017 Cooperative 
Agreement. 
Aspirational                        Requirements from the 
Capabilities                         2017 Cooperative Agreement* 
Establish an HCC Characterize populations at risk 
Foundation for  Identify HCC members Ensure sustainability and HCC value 
1
Health Care and  Establish HCC governance Engage executives, clinicians, and 
Medical  Develop a preparedness plan  community leaders  
Assess hazard vulnerabilities and risks Implement National Incident 
Readiness
Assess regional health care resources Management System  
 
2 Health Care and  Develop HCC response plan  
Medical Response  Coordinate public health and health 
care emergency information sharing
Coordination
Continuity of  Develop and implement continuity of 
3
operations plan
Health Care 
Assess supply chain integrity
Service Delivery
Protect the health care workforce
4 Coordinate volunteers Assess immediate bed availability 
Medical Surge
Conduct coalition surge test Address specialty surgepediatric 
Develop and implement crisis care  care, chemical/radiation, burn and 
strategies and crisis standards of care trauma, behavioral health, 
Assess alternate care systems infectious disease 
 
 
 
Source:  CDC and ASPR.  2017-2022 Hospital Preparedness Program (HPP)Public Health Emergency Preparedness (PHEP) Cooperative Agreement, 
CDC-RFA-TP17-1701, 2017.  Accessed at https://www.grants.gov/web/grants/search-grants.html?keywords=CDC-RFA-TP17-1701 on February 2, 
2019 and ASPR  2017-2022 Health Care Preparedness and Response Capabilities.  Accessed at https://www.phe.gov/Preparedness/planning/hpp/rep
orts/Documents/2017-2022-healthcare-pr-capablities.pdf on August 20, 2019. 
* The 2017 Cooperative Agreement requirements listed here are requirement categories, under which more requirements are specified.   
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  APPENDIX B: Related OIG Work 
Exhibit B-1: OIG has previous studies related to health care facility emergency preparedness 
Title  Report Number  Date Issued 
Hospitals Reported Improved Preparedness for Emerging  OEI-06-15-00230  October 2018 
Infectious Diseases After the Ebola Outbreak 
This report found most U.S. hospitals reported that they were not prepared for the 2014 Ebola outbreak, but they 
have since acted to improve preparedness for emerging infectious diseases.  Hospitals reported improved 
preparedness by 2017, although hospital administrators expressed concerns about sustaining preparedness over 
time.  There is one unimplemented recommendation related to coordination among ASPR, CDC, and CMS 
regarding guidance and practical advice. 
Gaps Continue To Exist in Nursing Home Emergency  OEI-06-09-00270  April 2012 
Preparedness and Response During Disasters: 20072010 
In this followup to the 2006 study above, OIG found that the gaps identified in 2006 still existed.35  OIG 
recommended that CMS revise Federal regulations to include emergency preparedness requirements.  CMS 
implemented this recommendation in the form of the CMS emergency preparedness CoPs.    
OIG Memorandum Report: Supplemental Information  OEI-06-09-00271  April 2012 
Regarding the Centers for Medicare & Medicaid Services' 
Emergency Preparedness Checklist for Health Care 
Facilities 
This memorandum issued with the 2012 report above stated that CMS could improve its checklist for health care 
facilities to use during emergency preparedness planning, including possible collaboration with HCCs. 
State and Local Pandemic Influenza Preparedness:   OEI-02-08-00210  September 2009 
Medical Surge 
This report found that hospitals could improve planning and coordination for medical surge during influenza 
pandemics.  OIG recommended that, in collaboration with CDC, ASPR should continue to emphasize the 
importance of coordination involving a wide array of partners in medical surge and pandemic planning.  In 
May 2009, ASPR implemented all OIG report recommendations and the U.S. Department of Health and Human 
Services developed a handbookMedical Surge Capacity and Capability: The Healthcare Coalition in Emergency 
Response and Recoverythat guides the creation of HCCs that include key health care providers.   
Nursing Home Emergency Preparedness and Response  OEI-06-06-00020  August 2006 
During Recent Hurricanes 
This study found that nursing homes in the Gulf States experienced problems during Hurricanes Ivan, Katrina, Rita, 
and Wilma because of lack of effective planning and failure to execute emergency plans properly, even though they 
complied with Federal interpretive guidelines for emergency preparedness.  In response, CMS developed a checklist 
for nursing facilities to use for emergency preparedness planning.36    
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  APPENDIX C: Detailed Methodology 
Sample Selection 
To select a purposive sample of HCCs, we considered the HCCs regional 
location, the HCCs jurisdictional population, and whether the HCCs 
experienced a disaster in 2017 according to FEMAs Disaster Database.  To 
do this, we first stratified the population of 476 HCCs that received HPP 
funding in the 20172019 project cycle by the 10 HHS regions.  Then, we 
used the 2010 United States Decennial Census data to determine each 
HCCs jurisdictional population.37  HCCs had jurisdictional populations 
ranging from 1,394 people to more than 16.8 million people and had 
between 0 and 4 FEMA-declared disasters.38  We purposively selected 
20 HCCs that varied in population and in number of disasters.  There were 
two HCCs from each HHS region, and no State was represented more than 
once.  After we started data collection, one HPP awardee informed us that 
the States HCCs had consolidated.  Therefore, we recategorized that HCC 
from having a small jurisdictional population to having a large one.               
Exhibit C-1: The States from which we selected our sample of HCCs 
(which varied by population served and as to whether the selected 
HCCs experienced a FEMA-declared disaster in 2017) 
  Small HCC Population  Large HCC Population 
No  Utah  North Carolina 
FEMA-Declared  Oregon  Pennsylvania 
West Virginia  Illinois 
Disasters in 
Connecticut  Arizona 
2017 
  Minnesota 
Colorado 
At Least One  California  Florida 
FEMA-Declared  New Hampshire  Puerto Rico 
Oklahoma  Texas 
Disaster in 2017 
Idaho  Kansas 
Nebraska  New York 
Source:  OIG analysis of HHS regional boundaries, 2010 Census data, and 2017 FEMA-declared disasters. 
Note:  We used the median jurisdictional population of all 476 HCCs (i.e., 571,000 people) to characterize 
HCCs jurisdictional populations as small or large.  No HCCs in our sample had a population equal to 
the median. 
 
For each sampled HCC, we also selected its respective HPP awardee (i.e., the 
State or Territory that administers funding to the HCC).  This method 
resulted in 20 HPP awardees (out of a total of 62 HPP awardees receiving 
HPP funds).  HPP awardees in our sample administered HPP funding to a 
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  total of 219 HCCs, with each HPP awardee overseeing from 4 to 57 HCCs 
according to the data available at the time of our sampling.   
Data Collection 
We conducted structured interviews, administered surveys, and collected 
documentation for the 20 HCCs and the 20 HPP awardees in our sample.  
We asked HPP awardees about their experiences regarding all the HCCs in 
their jurisdiction and not only about the HCCs in our sample.  In our 
documentation collection, we gathered each of the 20 selected HCCs most 
recent HVA and membership lists.  We collected this data between 
November 2018 and January 2019. 
During our interviews with the 20 HCCs and 20 HPP awardees, we asked 
respondents to describe strategies and experiences in engaging and 
coordinating with a diverse community and health care partners.  We also 
asked respondents to describe any best practices, challenges, or concerns in 
adhering to 2017 Cooperative Agreement requirements and ASPR guidance.  
Finally, we asked respondents about the accessibility and usability of ASPR 
guidance and technical assistance when engaging, coordinating, and 
integrating diverse community and health care partners.  We administered 
surveys to further determine what ASPR guidance HCCs and HPP awardees 
found helpful. 
We also collected 2017 and 2019 Cooperative Agreement requirements and 
ASPR guidance, including the ASPRs Capabilities Document.  Additionally, 
we interviewed ASPR staff to seek clarification and further understand both 
the goals of the HPP regarding whole community emergency response, as 
well as ASPRs oversight of HPP.   
Data Analysis 
To determine the extent to which HCCs and HPP awardees reported 
preparing a diverse group of core and ancillary members and to determine 
the challenges and benefits associated with this, we conducted qualitative 
data analysis on the interview responses from the 20 HCCs and 20 HPP 
awardees.  Through several rounds of reviewing interview responses, we 
identified themes that were common among the interviews.  We grouped 
these themes into common categories which we developed into findings.  
For the purposes of this study, we considered HCCs to have grown 
strategically if they prioritized membership on the basis of assessments of 
their respective health care systems gaps in preparedness and response.    
We also analyzed HCC membership lists for the 20 selected HCCs to help 
corroborate interview responses.  HCCs presented their membership data in 
a variety of ways (e.g., a list of attendees at the most recent meeting, 
an Excel spreadsheet created in response to our inquiry) and may also 
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  define members differently.  We did not independently verify that these 
members fulfill the HPP membership requirements of an HCC member.  
That is, these members may or may not be entities within the HCCs defined 
boundaries that contribute to HCC strategic planning; identification of 
health care systems gaps in preparedness and response and mitigation 
strategies for those gaps; operational planning and response; information 
sharing; and resource coordination and management.   
To determine which ASPR guidance HCCs and HPP awardees found helpful, 
we analyzed interview and survey responses.  Further, to identify potential 
misinterpretations of the guidance (i.e., misinterpretations of the 2017 and 
2019 Cooperative Agreements and ASPRs Capabilities Document), we 
reviewed interview responses from HCCs and HPP awardees and compared 
them to the ASPR guidance and requirements from the 2017 Cooperative 
Agreement.  Additionally, we analyzed these documents to determine 
instances of possibly unclear or conflicting language.  We also reviewed 
responses from our interviews with ASPR staff to understand Cooperative 
Agreement requirements and ASPR guidance.  
   
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  APPENDIX D: Additional Ancillary Member 
Types Included in HCC Membership Lists  
Exhibit D-1: Number of HCC membership lists that reported at least 
one member of the additional ancillary member types  
Ancillary members subject to CMSs emergency  Number of HCCs 
preparedness CoPs  reporting member type 
Community mental health centers  10 
End-stage renal disease facilities  10 
Ambulatory surgery centers  9 
Intermediate Care Facilities for Individuals With  5 
Intellectual Disabilities 
Psychiatric residential treatment facilities  5 
Religious nonmedical health care institutions  3 
Organ procurement organizations  1 
Other ancillary members not subject to CMSs   
emergency preparedness CoPs 
Nongovernmental and volunteer organizations*  10 
Other local, State, and/or Tribal government  10 
agencies 
Academic or research institutions  8 
Local health care professional organizations (e.g.,  8 
hospital associations) 
Public safety and law enforcement  7 
Information management and infrastructure  5 
organizations 
Non-health-care-related businesses (e.g.,  5 
automotive networks or consultants) 
Other health care facilities (e.g., alternative  5 
medicine facilities; clinical labs; trauma and burn 
centers; substance abuse facilities; pharmacies; and 
medical suppliers) 
Schools  5 
Cities, counties, parishes, townships, and Tribes  4 
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  Social and human services  4 
Other ancillary members not subject to CMSs  Number of HCCs 
emergency preparedness CoPs   reporting member type 
Housing and shelter services  3 
Coroners  3 
Blood banks  2 
Dental offices  2 
Poison control  2 
* This category includes the American Red Cross and the Medical Reserve Corps (MRC).  The MRC is an 
ASPR-sponsored network of community-based volunteers, initiated and established by local 
organizations to meet the public health needs of their communities. 
Source: OIG analysis of membership lists for 20 selected HCCs, 2019. 
Note:  We reviewed membership lists to identify at least one member in each member type.  An HCC 
may not be included in those reporting each member type for one or more of four reasons:  (1) the HCC 
did not report the member type on its membership list because it mistakenly left a member off the list; 
(2) the HCC did not report the member type because no entities of that member type fall within the 
HCCs jurisdiction; (3) the HCC did not report the member type because entities of that member type fall 
within the HCCs jurisdiction but are not members; and/or (4) the HCC reported the member type on its 
membership list but did not provide sufficient information about the member for us to categorize it, and 
our independent research about the member did not reveal information that would allow us to 
categorize it.  We did not determine the extent to which any of these four factors affected our analyses.   
 
  
   
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  APPENDIX E: Excerpts of Unclear 2017 
Cooperative Agreement Requirements and 
Guidance Regarding HCC Membership  
Exhibit E-1: Two different HCC documentsthe 2017 Cooperative Agreement and ASPRs 
Capabilities Documentprovide information about membership and the expectations related to 
ancillary members that can be interpreted in different ways  
Cooperative Agreement requirement or ASPR  Cooperative Agreement requirement or ASPR 
guidance excerpts suggesting that all health care  guidance excerpts suggesting that HCCs should 
facilities and community entities should be HCC  use assessments to prioritize HCC members  
members   
 HPP awardees must ensure that there are no geographic gaps   HCCs must collaborate with a variety of stakeholders to 
in HCC coverage and that all interested health care facilities,  ensure the community has the necessary medical 
including independent facilities, are able to join an HCC, if  equipment and supplies, real-time information, 
desired.  (2017 Cooperative Agreement, p. 17)  communication systems, and trained and educated health 
  care personnel to respond to an emergency.  These 
 The HCC should liaise with the broader response community on a  stakeholders include core HCC members and additional 
regular basis...Additional HCC members may include but are not  HCC members... HCCs should include a diverse 
limited to the following: *  membership to ensure a successful whole community 
o  Behavioral health services and organizations  response.  (2017 Cooperative Agreement, p. 18) 
o  Community Emergency Response Team and Medical   
Reserve Corps    The HCC and its members should use the information 
o  Dialysis centers and regional end-stage renal disease  about these risks and needs (from HVAs) to ... prioritize 
(ESRD) networks  strategies to close or mitigate preparedness and response 
o  Federal facilities   gaps within their boundaries.  (2017 Cooperative 
o  Home health agencies   Agreement, p. 22) 
o  Infrastructure companies    
o  Jurisdictional partners   The HCC should Include enough members to ensure 
o  Local chapters of professional organizations   adequate resources; however, at the same time, having too 
o  Local public safety agencies   many members may make the HCC unmanageable 
o  Medical and device manufacturers and distributors  (ASPRs Capabilities Document, p. 11) 
o  Non-governmental organizations    
o  Outpatient health care delivery    HCC members should perform an assessment to identify 
o  Primary care providers  the health care resources and services that are vital for 
o  Schools, universities, and academic medical centers  continuity of health care delivery during and after an 
o  Skilled nursing, nursing, and long-term-care facilities  emergency.  (ASPRs Capabilities Document, p. 14) 
o  Support service providers (e.g., clinical laboratories, 
pharmacies, radiology, blood banks, poison control 
centers) 
o  Other (e.g., child care services, dental clinics, social work 
services, faith-based organizations) (ASPRs Capabilities 
Document, p. 11) 
 
Note:  OIG italicized phrases above to add emphasis.   
* In the interest of space, we removed some examples of facilities which appear in the original list of possible members.   
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  APPENDIX F: Agency Comments   
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OEI-04-18-00080    33 
  ACKNOWLEDGMENTS  
Lauren Buss served as the team leader for this study, and 
Margaret Naughton served as the lead analyst.  Others in the Office of 
Evaluation and Inspections who conducted the study include 
Taylor Eastman and Lori Jouty.  Office of Evaluation and Inspections staff 
who provided support include Althea Hosein, Seta Hovagimian, and 
Christine Moritz.  
This report was prepared under the direction of Dwayne Grant, Regional 
Inspector General for Evaluation and Inspections in the Atlanta regional 
office; Evan Godfrey, Deputy Regional Inspector General; and Jaime Stewart, 
Assistant Regional Inspector General.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
To obtain additional information concerning this report or to obtain copies, 
contact the Office of Public Affairs at Public.Affairs@oig.hhs.gov.  
Selected Health Care Coalitions Increased Involvement in Whole Community Preparedness But Face Developmental Challenges 
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OEI-04-18-00080    34 
  ABOUT THE OFFICE OF INSPECTOR GENERAL 
The mission of the Office of Inspector General (OIG), as mandated by Public 
Law 95-452, as amended, is to protect the integrity of the Department of 
Health and Human Services (HHS) programs, as well as the health and 
welfare of beneficiaries served by those programs.  This statutory mission is 
carried out through a nationwide network of audits, investigations, and 
inspections conducted by the following operating components: 
Office of Audit  The Office of Audit Services (OAS) provides auditing services for HHS, either 
by conducting audits with its own audit resources or by overseeing audit 
Services 
work done by others.  Audits examine the performance of HHS programs 
and/or its grantees and contractors in carrying out their respective 
responsibilities and are intended to provide independent assessments of 
HHS programs and operations.  These audits help reduce waste, abuse, and 
mismanagement and promote economy and efficiency throughout HHS. 
Office of Evaluation  The Office of Evaluation and Inspections (OEI) conducts national evaluations 
to provide HHS, Congress, and the public with timely, useful, and reliable 
and Inspections 
information on significant issues.  These evaluations focus on preventing 
fraud, waste, or abuse and promoting economy, efficiency, and 
effectiveness of departmental programs.  To promote impact, OEI reports 
also present practical recommendations for improving program operations.   
Office of  The Office of Investigations (OI) conducts criminal, civil, and administrative 
investigations of fraud and misconduct related to HHS programs, 
Investigations 
operations, and beneficiaries.  With investigators working in all 50 States 
and the District of Columbia, OI utilizes its resources by actively 
coordinating with the Department of Justice and other Federal, State, and 
local law enforcement authorities.  The investigative efforts of OI often lead 
to criminal convictions, administrative sanctions, and/or civil monetary 
penalties. 
Office of Counsel to  The Office of Counsel to the Inspector General (OCIG) provides general 
legal services to OIG, rendering advice and opinions on HHS programs and 
the Inspector 
operations and providing all legal support for OIGs internal operations.  
General 
OCIG represents OIG in all civil and administrative fraud and abuse cases 
involving HHS programs, including False Claims Act, program exclusion, and 
civil monetary penalty cases.  In connection with these cases, OCIG also 
negotiates and monitors corporate integrity agreements.  OCIG renders 
advisory opinions, issues compliance program guidance, publishes fraud 
alerts, and provides other guidance to the health care industry concerning 
the anti-kickback statute and other OIG enforcement authorities. 
  ENDNOTES 
 
1 Tampa Bay Health & Medical Preparedness Coalition, Homeland Security Exercise and 
Evaluation Program (HSEEP) After Action Report/Improvement Plan: Hurricane Irma, 
November 7, 2017.   
2 ASPR, Hospital Preparedness Program: HPP Prepares the Nations Health Care System 
To Save Lives During Emergencies and Disasters.  Accessed at https://www.phe.gov/ 
Preparedness/planning/hpp/Documents/hpp-intro-508.pdf on May 13, 2019.   
3 The Coronavirus Aid, Relief and Economic Security Act (i.e., Cares Act) appropriated at least 
$250 million additional funds to the HPP.  H. R. 748275.  Accessed at 
https://www.congress.gov/116/bills/hr748/BILLS-116hr748enr.pdf on April 21, 2020.  
4 The large metropolitan local governments include Chicago; Los Angeles County; 
New York City; and Washington, DC.  The territories include American Samoa, Guam, the 
Northern Mariana Islands, Puerto Rico, and the U.S. Virgin Islands.  The Freely Associated 
States include the Republic of Palau, the Federated States of Micronesia, and the Republic of 
the Marshall Islands.   
5 According to ASPR officials, ASPR assumed responsibility for the HPPs grants-management 
function from the Centers For Disease Control and Preventions (CDCs) Office of Grants 
Services in 2018.  As a result, ASPR canceled the remainder of the 20172022 project cycle 
and ASPR and CDC developed and published separate Funding Opportunity 
Announcements, effective in fiscal year 2019. 
6 ASPR, Funding Opportunity Announcement and Grant Application Instructions Funding 
Opportunity Title: Hospital Preparedness Program Cooperative Agreement (CFDA # 93.889), 
pp. 4041.  Accessed at https://www.grants.gov/web/grants/search-grants.html on March 19, 
2019.     
7 ASPR, Hospital Preparedness Program: HPP Prepares the Nations Health Care System 
To Save Lives During Emergencies and Disasters.  Accessed at https://www.phe.gov/ 
Preparedness/planning/hpp/Documents/hpp-intro-508.pdf on May 13, 2019.   
8 CDC and ASPR, 20172022 Hospital Preparedness Program (HPP)Public Health Emergency 
Preparedness (PHEP) Cooperative Agreement, CDC-RFA-TP17-1701, March 22, 2017.  Accessed 
at https://www.grants.gov/web/grants/search-grants.html?keywords=CDC-RFA-TP17-1701 on 
February 2, 2019.  Page 105 states that ASPR still permits funding from awardees to individual 
health care entities in Budget Period 1.  However, ASPR expects that as the project period 
progresses, the awardees funding strategy will include allocating funding to HCCs in a 
graduated manner.  In this way, HCC funding should have increased incrementally over the 
5-year project period.  
9 Ibid. 
10 ASPR, Funding Opportunity Announcement and Grant Application Instructions Funding 
Opportunity Title: Hospital Preparedness Program Cooperative Agreement (CFDA # 93.889), 
p. 17.  Accessed at https://www.grants.gov/web/grants/search-grants.html on March 19, 2019. 
11 According to ASPR officials, ASPR has most recently issued 5-year cooperative agreements 
for the HPP.  The 2017 Cooperative Agreement includes Federal requirements, HPP program 
requirements, and HPP benchmarks that are applicable to HCCs and awardees.  Additionally, 
according to ASPR officials, ASPR issues continuation guidance in years 2 through 5 of the 
cooperative agreement with more specificity on how to meet requirements.   
 
   
12 CDC and ASPR, 20172022 Hospital Preparedness Program (HPP)Public Health Emergency 
Preparedness (PHEP) Cooperative Agreement, CDC-RFA-TP17-1701, March 22, 2017.  Accessed 
at https://www.grants.gov/web/grants/search-grants.html?keywords=CDC-RFA-TP17-1701 on 
February 2, 2019.  Page 17 states that ASPR defines an HCC as a coordinating body that 
incentivizes diverse and often competitive health care organizations and other community 
partners with differing priorities and objectives and reach to community members to work 
together to prepare for, respond to, and recover from emergencies and other incidents that 
impact the publics health.   
13 Revisions to the 2017 Cooperative Agreement included (1) clarifying the matching funds 
requirement, (2) changing the date for submission of health care system recovery plans, 
(3) adding a funding restriction on training courses, and (4) revising acceptable items to 
attach to applications for HPP funding.   
14 Federal Emergency Management Agency (FEMA), Incident Command System Resources, 
June 26, 2018.  Accessed at https://www.fema.gov/incident-command-system-resources on 
July 30, 2019.  The Incident Command System is a management system designed to enable 
effective and efficient domestic incident management by integrating a combination of 
facilities, equipment, personnel, procedures, and communications operating within a 
common organizational structure.  
15 CDC and ASPR, 20172022 Hospital Preparedness Program (HPP)Public Health Emergency 
Preparedness (PHEP) Cooperative Agreement, CDC-RFA-TP17-1701, March 22, 2017.  Accessed 
at https://www.grants.gov/web/grants/search-grants.html?keywords=CDC-RFA-TP17-1701 on 
February 2, 2019.  Page 18 states that HCCs must include as members a minimum of two 
acute-care hospitals. 
16 Ibid.  Page 18 states that emergency medical services include inter-facility and other 
non-EMS patient transport systems. 
17 ASPR, 20172022 Health Care Preparedness and Response Capabilities.  Accessed at 
https://www.phe.gov/Preparedness/planning/hpp/reports/Documents/2017-2022-
healthcare-pr-capablities.pdf on August 20, 2019.  
18 ASPR, 20172022 Health Care Preparedness and Response Capabilities.  Accessed at 
https://www.phe.gov/Preparedness/planning/hpp/reports/Documents/2017-2022-
healthcare-pr-capablities.pdf on August 20, 2019.  The capabilities are not requirements in 
the 2017 Cooperative Agreement, but rather high-level guidance for the preparedness of the 
Nations health care delivery system, including HCCs and individual health care organizations.   
19 CMS, Emergency Preparedness Rule.  Accessed at https://www.cms.gov/medicare/provider-
enrollment-and-certification/surveycertemergprep/emergency-prep-rule.html on May 28, 
2019. 
20 CMS, Providers/Suppliers Facilities Impacted by the Emergency Preparedness Rule.  Accessed 
at https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/ 
SurveyCertEmergPrep/Downloads/17-Facility-Provider-Supplier-Types-Impacted.pdf on 
September 10, 2019.  This CMS list treats critical access hospitals separately from other 
hospitals.  For our purposes, however, we counted all hospital types, including critical access 
hospitals, as core HCC members.       
21 CMS, Emergency PreparednessUpdates to Appendix Z of the State Operations Manual, 
February 1, 2019.  Accessed at https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/SurveyCertificationGenInfo/Downloads/QSO19-06-ALL.pdf on March 5, 2020. 
22 FEMA, Fiscal Year (FY) 2019 Homeland Security Grant Program (HSGP) Frequently Asked 
Questions (FAQs).  Accessed at https://www.fema.gov/media-library-data/1555008515875-
 
   
3e335349f5d330de3f265af17c7e3409/FY19_HSGP_FAQ_FINAL_508.pdf on Novermber 21, 
2019.  
23 CDC, CDC: Mission, Role and Pledge, April 14, 2014.  Accessed at 
https://www.cdc.gov/about/organization/mission.htm on March 5, 2020. 
24 CDC, 2014 Ebola Response Supplemental Funding: PHEP Supplemental Funding for Ebola 
Preparedness and Response Activities, April 18, 2017.  Accessed at 
https://www.cdc.gov/phpr/readiness/funding-ebola.htm on March 5, 2020. 
25 CDC, CDC Increasing Supply of Ebola-specific Personal Protective Equipment for U.S. 
Hospitals.  Accessed at https://www.cdc.gov/media/releases/2014/p1107-ebola-PPE.html on 
March 5, 2020. 
26 CDC, Guidelines for Evaluation of US Patients Suspected of Having Ebola Virus Disease, 
distributed via the CDC Health Alert Network on August 1, 2014. 
https://stacks.cdc.gov/view/cdc/24727 on March 12, 2020. 
27 HRSA, Emergency Medical Services for Children State Partnership Program Funding 
Opportunity Number: HRSA-18-063. 2018.  Accessed at https://grants.hrsa.gov/2010/ 
Web2External/Interface/Common/EHBDisplayAttachment.aspx?dm_rtc=16&dm_attid= 
37cb5412-fe0d-4eb6-83a7-189a5af748d0 on November 21, 2019.  
28 NHTSA, EMS Improving Cardiac Arrest Response, CPR Training.  Accessed at 
https://www.nhtsa.gov/ems-improving-response-cardiac-arrests on November 21, 2019. 
29 NHTSA, Preparedness: Fostering Collaboration Across the Federal Government to Enhance 
Readiness for Catastrophic Incidents.  Accessed at https://www.ems.gov/preparedness.html 
on November 21, 2019. 
30 All 20 HCCs in our review reported that they conduct Hazard Vulnerability Assessments 
(HVAs).  However, only two reported using HVAs to inform membership decisions.   
31 Two of these four HCCs were among the five that use assessments.   
32 CDC and ASPR, 20172022 Hospital Preparedness Program (HPP)Public Health Emergency 
Preparedness (PHEP) Cooperative Agreement, CDC-RFA-TP17-1701, March 22, 2017.  Accessed 
at https://www.grants.gov/web/grants/search-grants.html?keywords=CDC-RFA-TP17-1701 on 
February 2, 2019.   
33 We reviewed the data for the HCC corresponding to the awardee that reported directing 
its HCCs to use HVAs to determine gaps in membership.  The HCC reported using member 
experience of the health care system to determine membership gaps. 
34 For the awardee in our review that did not know how its HCCs determined gaps in 
membership, we reviewed the data for the corresponding HCC in our review.  This HCC 
stated that it does not use an assessment to determine which entities should become HCC 
members, but determines membership on the basis of the needs of its key partners. 
35 OIG, Gaps Continue to Exist in Nursing Home Emergency Preparedness and Response 
During Disasters: 2007-2010, OEI-06-09-00270, April 2012.  Accessed at 
https://www.oig.hhs.gov/oei/reports/oei-06-09-00270.asp on August 29, 2019. 
36 CMS, Templates & Checklists.  Accessed at https://www.cms.gov/Medicare/Provider-
Enrollment-and-Certification/SurveyCertEmergPrep/Templates-checklists.html on May 22, 
2018.  CMS last revised this checklist in 2009. 
37 We used 2010 Census population data for all mainland HCCs and 2010 population data on 
local governmental websites for all territories and Freely Associated States.  In the master list 
of HCCs that ASPR provided to us, it included the county/counties that each HCC served.  
We matched these counties to their 2010 population data using relationship files that were 
 
   
accessed at https://www.census.gov/geo/maps-data/data/zcta_rel_download.html on 
June 13, 2018.    
38 While some HCCs did not appear as having any FEMA-declared disasters in 2017, we 
identified through interviews in some cases that an HCC may have responded to an 
emergency event that FEMA did not formally declare and was not captured in our sample 
selection methods.