Department of Health and Human Services 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
 
 
 
 
H E
  OSPITAL  MERGENCY 
 
P R
REPAREDNESS AND  ESPONSE 
 
 
D S S  
URING  UPERSTORM  ANDY 
 
 
Daniel R. Levinson   
Inspector General  
 
September 2014 
OEI-06-13-00260   
   
EXECUTIVE SUMMARY:  HOSPITAL EMERGENCY PREPAREDNESS AND 
RESPONSE DURING SUPERSTORM SANDY  
OEI-06-13-00260 
 
WHY WE DID THIS STUDY 
Federal regulations require that hospitals prepare for emergencies including natural disasters.  
The strength of Superstorm Sandy and the population density of the affected areas placed high 
demands on hospitals and related services.  Prior studies by the Office of Inspector General 
found substantial challenges in health care facility emergency preparedness and response.  In a 
2006 study, we found that many nursing homes had insufficient emergency plans or did not 
follow their plans. In a 2012 followup study, we found that gaps continued to exist in nursing 
home emergency preparedness and response.   
HOW WE DID THIS STUDY  
For this study, we surveyed 174 Medicare-certified hospitals located in declared disaster areas in 
Connecticut, New Jersey, and New York during Superstorm Sandy.  We also conducted site 
visits to 10 purposively selected hospitals located in areas most affected by the storm.  
Additionally, we examined information from State survey agency and accreditation organization 
surveys of hospitals conducted prior to the storm and spoke to surveyors about their survey 
process related to emergency preparedness.  We  also interviewed State hospital associations and 
health care coalitions in the three States.   
WHAT WE FOUND 
Most hospitals in declared disaster areas sheltered in place during Superstorm Sandy, and  
7 percent evacuated. Eighty-nine percent of hospitals in these areas reported experiencing 
substantial challenges in responding to the storm.  These challenges represented a range of 
interrelated problems from infrastructure breakdowns, such as electrical and communication 
failures, to community collaboration issues over resources, such as fuel, transportation, hospital 
beds, and public shelters. Hospitals reported that prior emergency planning was valuable during 
the storm and that they subsequently revised their plans as a result of lessons learned.  Prior to 
the storm, most hospitals received emergency-related deficiency citations from hospital 
surveyors, some of which related to the challenges reported by hospitals during Superstorm  
Sandy.   
WHAT WE RECOMMEND 
The experiences of hospitals during Superstorm Sandy and the deficiencies cited prior to the 
storm reveal gaps in emergency planning and execution that might be applicable to hospitals 
nationwide. Given that insufficient community-wide coordination among affected entities was a 
common thread through the challenges identified by hospital administrators, we recommend that 
the Office of the Assistant Secretary for Preparedness and Response (ASPR) continue to promote 
Federal, State, and community collaboration in major disasters.  We also recommend that the 
Centers for Medicare & Medicaid Services (CMS) examine existing policies and provide 
guidance regarding flexibility for reimbursement under disaster conditions.  ASPR and CMS 
concurred with the recommendations. 
   
TABLE OF CONTENTS 
 
Objectives ....................................................................................................1 

Background..................................................................................................1 

Methodology................................................................................................5 

Findings........................................................................................................8 

Most hospitals in declared disaster areas sheltered in place  

during Sandy, and 7 percent evacuated ............................................8 

Eighty-nine percent of hospitals reported experiencing critical 

challenges during Sandy, such as breakdowns in infrastructure  

and community collaboration ..........................................................9 

Hospitals reported that prior emergency planning was valuable 

during the storm and that they subsequently revised their plans  

as a result of lessons learned ..........................................................18 

Prior to the storm,  most hospitals received emergency- 

related deficiency citations from hospital surveyors .....................19 

Conclusion and Recommendations ............................................................22 

Agency Comments and Office of Inspector General Response .................24 

Appendixes ................................................................................................25 

Appendix A:  Methodology ...........................................................25 

Appendix B: Challenges Reported by Hospitals ..........................30 

Appendix C: Agency Comments ..................................................33 

Acknowledgments......................................................................................39 

 
   
   
OBJECTIVES 
1. 	  To describe the disaster experiences of hospitals affected by 
Superstorm Sandy, including challenges to hospital operations and 
patient care.  
2. 	  To determine the extent to which State survey agencies and 
accreditation organizations cited hospitals with emergency-related 
deficiencies prior to Superstorm Sandy. 
BACKGROUND 
Superstorm Sandy        
Superstorm Sandy (hereinafter referred to as Sandy) made landfall in the 
northeastern United States on October 29, 2012, severely damaging 
coastal areas of Connecticut, New Jersey, and New York.  Although Sandy 
had weakened from a hurricane by the time it reached the United States, 
the storm surge combined with high tides caused widespread flooding 
along the coastal areas. The storm claimed 72 lives and damage estimates 
totaled nearly $50 billion.1  In Connecticut, New Jersey, and New York, 
the Federal Government declared 40 counties as disaster areas.2  Within 
these counties are 174 Medicare-certified, short-term acute care hospitals, 
which are the subject of this report.3    
Federal Requirements for Hospital Emergency Preparedness 
Medicare Conditions of Participation. Medicare- and Medicaid-
participating hospitals must adhere to 23 Medicare Conditions of 
Participation.   The conditions are a set of minimum quality and safety 
standards, including requirements such as protecting patient rights and 
maintaining a physical environment that avoids transmission of infections 
and communicable diseases.4 One of these conditions requires that 
hospitals develop and implement a comprehensive emergency plan and 
maintain a physical environment (e.g., emergency power and lighting in 
____________________________________________________________ 
1 National Hurricane Center, Tropical Cyclone Report:   Hurricane Sandy (AL182012), 
February 12, 2013.  Accessed at http://www.nhc.noaa.gov/data/tcr/AL182012_Sandy.pdf   
on March 13, 2013.   At least 147 direct deaths were recorded across the Atlantic basin  
because of Sandy; 72 of these fatalities occurred in the mid-Atlantic and northeastern 
United States. 
2 Federal Emergency Management Agency  (FEMA), FEMA-4085-DR, FEMA-4086-DR, 
and FEMA-4087-DR.  Accessed at http://www.fema.gov on  March 4, 2013.  
3 Centers for Medicare & Medicaid Services (CMS) Certification and Survey Provider 
Enhanced Reports (CASPER).  
4 42 CFR   482.13 and  482.42. 
   
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operating, recovery, intensive care, and emergency rooms) that ensures the 
safety and well-being of patients during emergencies.5    
Hospitals must also meet applicable provisions of the Life Safety Code, 
including creating a written plan for the protecting and evacuating of all 
patients and conducting fire drills held at unexpected times under varying 
conditions.6  Other Life Safety Code requirements that hospitals must meet 
relate to the physical environment, such as ensuring that fire extinguishers 
are accessible, sprinkler systems are effective, passages are unobstructed, 
and exits are clearly marked.7  Additionally, hospitals with emergency 
departments must have adequate medical and nursing staff qualified to 
meet the emergency needs of patients.8    
On December 27, 2013, 14 months after Sandy made landfall, CMS issued 
a notice of proposed rulemaking to establish national emergency 
preparedness requirements for providers and suppliers participating in 
Medicare and Medicaid.  One of the proposed Medicare Conditions of 
Participation is that hospitals have an emergency plan and preparedness 
program that involves risk assessments, policies and procedures based on 
those assessments, communication plans that coordinate with external 
entities, and emergency training activities.9    
Medicare Oversight of Hospital Emergency Preparedness. CMS includes 
oversight of hospital emergency preparedness as part of its broader 
Medicare compliance surveys conducted by State survey agencies and 
CMS-approved accreditation organizations.10, 11  
Although State survey agencies use similar survey instruments and 
methodology, each accreditation organization uses its own process.  
____________________________________________________________ 
5 42 CFR   482.41; CMS State Operations Manual, Appendix  A - Survey Protocol,  
Regulations  and Interpretive Guidelines for Hospitals.  
6 42 CFR  482.41(b) (i).  The Life Safety  Code is a source for strategies to  protect  
people that is based on  building construction, protection, and occupancy features that  
minimize the effects of fire and related hazards.  Accessed at  http://www.nfpa.org on  
March 14, 2013. 
7 42 CFR   482.41(b)(i) states that the facility must meet the applicable provisions  of the 
2000 edition  of the Life Safety Code of the National Fire Protection Association (NFPA), 
which is incorporated in the regulation by reference. See NFPA  101  Life Safety  Code, 
2000 edition,   7.1.10;  7.10.1.4; and 19.2-3, 6-7. Accessed at  http://www.nfpa.org on  
March 14, 2013. 
8 42 CFR   482.55(b)(2). 
9 78 Fed. Reg. 79082-79200 (Dec. 27, 2013). 
10  Social Security Act (SSA);   1865(a)(1); 42 U.S.C. 1395bb.   
11 Four national accreditors review hospital compliance:  The Joint Commission (TJC), 
the American Osteopathic Association (AOA), Det Norske Veritas Healthcare 
(DNVHC), and the Center for Improvement in  Healthcare Quality (CIHQ). CMS, CMS-
Approved Accreditation Organizations, 2013. 
   
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During an accreditation survey, surveyors verify hospital compliance with 
the Medicare Conditions of Participation and additional performance 
standards imposed by the accrediting organization.12 If surveyors find that 
a hospital does not meet a particular condition, they can cite the hospital 
with one or more deficiencies to indicate noncompliance and require a 
corrective plan of action or follow up with an onsite visit to validate 
correction. To continue providing care to Medicare patients, hospitals 
must correct deficiencies within a given timeframe depending on the 
seriousness of the deficiency. 
CMS provides guidance to surveyors in its State Operations Manual.13   
The manual includes specific guidance regarding developing and 
accessing emergency plans, including requirements to identify and ensure 
availability of supplies and equipment, verify sufficient medical and 
nursing staff, and confirm a clear chain of command during disasters.14   
Hospitals may also use the manual as guidance in developing emergency 
plans. 
Other guidance that hospitals may use when developing or revising 
emergency plans includes a CMS emergency preparedness checklist for 
health care facilities.  The checklist provides the same guidance for all 
health care facilities, including hospitals, for developing emergency plans; 
ensuring adequate supplies of food and water; identifying evacuation 
routes; transporting patients, critical supplies, and equipment; and 
collaborating with local emergency management agencies, suppliers, and 
providers.15    
Federal Disaster Preparedness and Response Programs  
Two agencies within the Department of Health and Human Services 
(HHS) operate and fund disaster preparedness programs.  Through the 
Hospital Preparedness Program, the Office of the Assistant Secretary for 
Preparedness and Response (ASPR) funds grants and cooperative 
agreements with States, territories, and eligible municipalities to enhance 
community, hospital, and health care system preparedness for public 
____________________________________________________________ 
12 For example, TJC considers approximately 1,800 performance standards, only half of  
which correspond to a Medicare Condition of  Participation.  Office of Inspector General 
(OIG) interview with TJC officials, November 15, 2013.  
13 CMS, State Operations  Manual,  Pub. 100-07. 
14 CMS, State Operations  Manual, Appendix  ASurvey Protocol, Regulations and 
Interpretive Guidelines for Hospitals, pp. 223, 226228, and 360.  Accessed at 
http://www.cms.gov on May 24, 2011. 
15 CMS, Survey & Certification:  Emergency Preparedness  Checklist Recommended Tool  
for Effective Health Care Facility Planning.  Accessed at http://www.cms.gov  on  
February 5,  2010.   
   
Hospital Emergency Preparedness and Response During Superstorm Sandy  (OEI-06-13-00260)   3 
 
   
   
health emergencies.16, 17   Additionally, through the Public Health  
Emergency Preparedness Cooperative Agreements program, the Centers 
for Disease Control and Prevention (CDC) funds preparedness activities 
for State and local public health systems.18  
In the event of a disaster or emergency, the Federal Government uses the 
National Response Framework to guide its actions to save lives, protect 
property and the environment, stabilize affected areas, and meet basic 
human needs.19  Using this framework, when local jurisdictions or tribal 
governments have exhausted their resources in responding to a disaster or 
emergency, they may request assistance from the State.  When a disaster or 
emergency is beyond the capabilities of the State, the Governor or tribal 
government may seek Federal assistance.   Within this framework, HHS is 
responsible for planning and coordinating Emergency Support Function 
(ESF) #8 to address public health, medical, and human services needs 
during a public health or medical disaster or emergency, including patient 
evacuation and patient care.20   The Secretary of HHS leads the  
ESF #8 response which, when activated, is coordinated by ASPR.21, 22    
Office of Inspector General Reports 
Prior studies by OIG on health care facility emergency preparedness found 
substantial challenges in both planning and execution.  In a 2006 report, 
we found that a sample of 20 nursing homes had emergency plans that 
often lacked information suggested by experts.  During emergencies, 
nursing home administrators and staff sometimes did not follow their 
emergency plans and insufficient collaboration between State and local 
emergency entities and nursing homes impeded emergency preparedness 
____________________________________________________________ 
16 HHS, ASPR, Hospital Preparedness Program Overview.  Accessed at 
http://www.phe.gov  on March 26, 2013.  
17 In fiscal year  2014, ASPRs Hospital Preparedness Program budget  was reduced  by  
$103 million (33 percent of its overall  budget).  Given the funding reduction, ASPR  
anticipates that many awardees will absorb the reduction  in awards by  scaling back on  
emergency preparedness activities, including  exercises and training.  OIG conversation 
with ASPR, May 2, 2014.  
18 HHS, CDC, Public Health Emergency Preparedness Cooperative Agreements.   
Accessed at http://www.cdc.gov on March 26, 2013. 
19 Department of Homeland Security (DHS),  National Response Framework, January 
2008, p.  1, 12.  Accessed at  http://www.fema.gov/pdf/emergency/nrf/nrf-core.pdf on  May  
26, 2013.  The second  edition was published after Sandy in May 2013. 
20 DHS, Emergency Support  Function #8Public  Health and  Medical Services Annex, 
January 2008, p. 1-2.  Accessed at http://www.fema.gov/pdf/emergency/nrf/nrf-esf-
08.pdf  on May 26, 2013.  The ESF #8  Annex was revised in May 2013. 
21  Pandemic  and All-Hazards Preparedness Act  of 2006, P.L. No. 108-173  102.  
22 For more information on the National Response Framework and each Federal agencys 
responsibilities during disasters, see http://www.fema.gov/media-library-data/20130726-
1914-25045-1246/final_national_response_framework_20130501.pdf . 
   
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and management.23  Subsequent to the 2006 report, CMS developed the 
previously mentioned emergency preparedness checklist for health care 
facilities.24    
In a 2012 followup report, OIG found that gaps continued to exist in 
health care facility emergency preparedness and response.25   
Administrators from nursing homes reported challenges such as following 
emergency plans as written, logistical problems related to transportation 
and communication, and negative effects of evacuation on resident health.  
We recommended that CMS revise Federal regulations to include 
requirements for specific elements of emergency plans and training, 
update the State Operations Manual to provide detailed and clear guidance 
for surveyors assessing compliance with Federal standards, and promote 
use of the checklist.  Additionally, in a 2012 memorandum report, OIG 
outlined guidance that CMS could consider when revising its emergency 
preparedness checklist for health care facilities.26, 27    
METHODOLOGY 
Report findings are based on multiple data collection activities and 
sources. We administered electronic questionnaires to the 174 Medicare-
certified, short-term acute care hospitals located in the 40 counties 
declared as disaster areas in Connecticut, New Jersey, and New York (see 
Figure 1 for a map of the counties declared as disaster areas and        
Figure A-1 in Appendix A for a map of the hospitals located in the affected 
areas). We received survey responses from 172 of the 174 hospitals.  We  
also conducted site visits to 10 purposively selected hospitals located in 
areas most affected by the storm.   
Additionally, we examined surveys conducted by the State survey 
agencies and accreditation organizations of hospitals in the affected areas 
  ____________________________________________________________ 
23 HHS, OIG,  Nursing  Home Emergency Preparedness and  Response During Recent  
Hurricanes,  OEI-06-06-00020, August 2006.     
24 CMS, Survey & Certification:  Emergency Preparedness  Checklist Recommended Tool  
for Effective Health Care Facility Planning, September 2007.  The checklist was revised  
in September 2009.  Accessed at http://www.cms.gov  on February  5, 2010.   
25 HHS, OIG,  Gaps Continue To Exist in Nursing Home Emergency Preparedness and 
Response During Disasters:  2007-2010, OEI-06-09-00270, April 2012.   
26 HHS, OIG,  Supplemental Information Regarding the Centers for Medicare &  
Medicaid  Services' Emergency Preparedness Checklist for Health Care Facilities, 
OEI-06-09-00271, April 2012.   
27 In December 2013, CMS revised the checklist according to the outlined  guidance in the  
2012  OIG memorandum report.  CMS, Survey & Certification:  Emergency 
Preparedness  Checklist Recommended Tool for Effective Health Care Facility Planning. 
Accessed at http://www.cms.gov  on March 26, 2014.    
   
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prior to the storm and spoke to the surveying entities about their survey 
processes related to emergency preparedness.  We reviewed surveys for  
171 of the 174 hospitals.28   We also conducted telephone interviews with 
State hospital associations and health care coalitions in the three States.29   
(See Appendix A for a complete description of the methodology.) 
 
Figure 1: Map of Counties Declared as Disaster Areas as a Result of 
  Sandy  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Source:  FEMA, FEMA-4085-DR, FEMA-4086-DR, and FEMA-4087-DR. Accessed at  http://www.fema.gov  
 
on March 4, 2013. 
 
Limitations 
Sandy affected numerous States along the east coast.  However, we 
selected only the 3 States that were most heavily affected by the storm and 
the 40 counties within those States that were declared as disaster areas.  
For this reason, experiences of these hospitals may not be reflective of 
experiences of hospitals in other States or counties.  Also, we did not 
interview State or local emergency management entities to verify the 
 
____________________________________________________________ 
28  We  did not  receive surveys for three hospitals because of  unavailable data. 
29 A health care coalition is a group  of  health  care organizations and public safety and  
public health  partners that join  forces for the common cause of making their communities 
safer,  healthier, and more resilient before, during, and after disasters and other crises.  
National Healthcare Coalition Resource Center.  Accessed at  
http://healthcarecoalitions.org on January 2,  2014. 
   
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information provided by hospitals related to their involvement during 
Sandy. Further, we requested from  accreditation organizations and State 
survey agencies surveys of only the selected hospitals.  Therefore, 
deficiency data are not projectable to other hospitals.  Lastly, we did not 
directly link survey deficiency data to challenges reported by specific 
hospitals because hospitals responded to the questionnaire anonymously. 
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors General 
on Integrity and Efficiency. 
   
   
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FINDINGS 
Most hospitals in declared disaster areas sheltered in 
place during Sandy, and 7 percent evacuated 
Sandy affected many aspects of hospital operations, and ultimately  
93 percent of hospitals (160 of 172) sheltered in place, while  
7 percent of hospitals (12 of 172) either evacuated (9) or partially 
evacuated (3).  Despite the challenging circumstances, according to ASPR, 
hospitals did not experience any patient deaths as a result of the storm.    
Several factors strongly influenced whether hospitals were able to shelter 
in place or forced to evacuate all or some of their patients.  For example, 
location of the hospital near a flood zone, projections of poor weather, and 
concerns about the structural integrity of the hospital might influence a 
hospital to evacuate.  Additionally, hospitals reported that prior experience  
with hurricanes, including Hurricane Irene a year prior, strongly 
influenced their disaster response. 
Hospitals that sheltered in place served several functions 
during the storm, including receiving patients from other 
health care facilities and providing care to the public  
Of the hospitals that sheltered in place, 65 reported receiving patients from 
other hospitals. Receiving patients required hospitals to coordinate with 
outside entities, bolster supplies and staff, and reduce the number of 
existing patients prior to Sandys landfall.  These outside entities included 
local emergency management agencies, police departments, State health 
departments, and evacuating hospitals.  To reduce their patient populations 
prior to the storm,  many hospitals discharged patients identified as safe for 
discharge, canceled elective surgeries and procedures, and redistributed 
patients across multiple departments to enable a more evenly divided use 
of resources. Specifically, 117 hospitals that sheltered in place reported 
discharging patients whom hospital staff had identified as safe for 
discharge, on the basis of their conditions, and the availability of 
caregivers and a home or other destination located outside flood and 
evacuation zones. During hospital site visits, administrators described 
how hospitals also served as shelters for people in the community (with 
and without medical needs) given that the hospitals were often the only 
buildings nearby with electricity.     
For hospitals that evacuated all or some of their patients, 
evacuations typically occurred  in two challenging stages 
Prior to the storm, evacuating hospitals took actions similar to those of 
hospitals that sheltered in place and discharged as many patients as 
possible whom staff had identified as safe for discharge, canceled elective 
   
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surgeries and procedures, and closed their emergency departments.  
Following that, with transportation assistance from local emergency 
management and State health departments, hospitals moved remaining 
patients to other hospitals. For three hospitals, evacuation was delayed 
and more complicated.  These hospitals had initially intended to shelter in 
place, but later decided to evacuate. One of these hospitals began 
evacuating shortly before Sandy made landfall.  Soon thereafter the 
hospital flooded. The other two hospitals evacuated the day after the 
storm made landfall, having lost electric and gas utilities and being 
surrounded by water. 
Hospitals that partially evacuated faced the additional challenge of  
coordinating which patients to evacuate and which to shelter in place.  
These hospitals had initially decided to shelter all of their patients, but 
later decided to evacuate some to other hospitals.  One hospital reported 
sheltering the most critically ill or fragile patients, while evacuating the 
less critical patients to other hospitals within its network.  Staff  
consolidated the critical patients that remained to the safest floors and the 
hospital moved its command center nearby so that staff and patients were 
at one location. To ensure continuity of care for evacuated patients, the 
hospital sent nurses, nurse assistants, and leadership staff to the receiving 
hospitals and reported that doing so relieved some of the anxiety of 
evacuating for patients and their families.   
Eighty-nine percent of hospitals reported experiencing  
critical challenges during Sandy, such as breakdowns 
in infrastructure and community collaboration 
Most hospitals (153 of 172) reported facing substantial challenges when 
responding to the storm, whether they evacuated or sheltered in place.30   
These challenges represented a range of interrelated problems from  
infrastructure breakdowns, such as electrical and communication failures, 
to community collaboration issues over resources, such as fuel, 
transportation, hospital beds, and public shelters.  In reviewing the 
challenges reported by hospitals, we identified two broad problems:  
patient care and staffing.  (See Appendix B for a table of challenges 
reported by hospitals.) 
 
 
 
____________________________________________________________ 
30 The remaining 11  percent  of hospitals (19 of  172) reported that they  did not experience 
substantial challenges during Sandy. 
   
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Hospitals reported that infrastructure breakdowns, such as 
electrical failures, affected patient care during the storm 
Approximately half of hospitals in the declared disaster areas (83 of 172) 
reported challenges with their facility infrastructure when responding to 
Sandy. Of these hospitals, 18 reported flooding as a result of the storm  
(see Figure 2). The floods severely affected hospitals, whether a few 
inches of water penetrated facility entryways or several feet of water 
subsumed hospital corridors.  In one hospital, only 1 inch of water entered 
the building but the effect was still significant in that the water 
compromised the backup generator, forcing the hospital to evacuate when  
it lost electrical power. Another hospital, along with its surrounding 
community, was inundated with several feet of water.  This hospital 
eventually evacuated, as substantial flood water, rising out of the sewer, 
disabled its generators and water supply. 
  Figure 2: Flooding in One Hospital During Sandy 
 
 
 
 
 
 
 
 
 
Photo courtesy of Paul Walker, Hoboken University Medical Center.  Used with permission.  
For 29 hospitals, structural damage caused by flood and wind was a 
significant challenge for hospital operations during the storm.  Some  
hospitals continued to struggle with the physical damage caused by Sandy 
long after the storm as they recovered full operations.  One hospital 
sustained damage so severe that most of its services (e.g., emergency,  
inpatient, and outpatient services) remained closed at the time of our 
evaluation, nearly a year after the storm.    
Widespread power outages forced hospitals to rely on backup generators 
and use alternative procedures when delivering care to patients. Of 
hospitals in declared disaster areas, 69 reported experiencing electrical 
utility outages, and for more than one-third of these hospitals (28 of 69), 
backup generators were not a reliable power source.  One hospital 
described how within 30 minutes after a nearby river overflowed the 
banks, water had disabled all power and turned the hospital completely 
   
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dark. Although this hospital placed its backup generators on the 13th floor,  
away from potential flooding, the fuel pumps were located in the flooded 
basement.  To keep the generators running, the hospital created a bucket 
line in which staff passed fuel up 13 flights of stairs until the hospital 
could evacuate hours later (see Figure 3).  Although it never carried them  
out, this same hospital reported making decisions about which machine-
dependent patients to keep on the limited number of emergency power 
outlets and which ones to take off life support machines in the event of 
power disruption. 
 
Figure 3: Fuel Bucket Line in One Hospital During 
Sandy  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  Photo courtesy of NYC Health and Hospitals Corporation.  Used with permission. 
During hospital site visits, administrators reported that some staff 
struggled to use alternative procedures when delivering care to patients 
during the extended power outages. For example, administrators in one 
hospital described how staff were accustomed to relying on intravenous 
therapy (IV) pumps to deliver fluids to patients, but now had to count 
drips manually to ensure that the pumps delivered fluid at the proper rate.  
Administrators from another hospital indicated that new and inexperienced 
nurses had little knowledge of alternative procedures.  This hospital held 
crash courses during the storm to teach staff alternative procedures, such 
as manually suctioning intubated patients. 
 
   
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Power failures affected hospital access to patient medical records, crucial 
for providing appropriate patient care. Seven hospitals reported problems 
with accessing medical records during the storm.  In one of these 
hospitals, most medical records, computers, and hospital files were 
destroyed by flooding. Another hospital reported receiving patients from a 
nearby hospital without medical records because the records were 
electronic and inaccessible without power.  The only information that the 
evacuating hospital could provide were oral histories by caregivers 
evacuating with their patients.  Administrators from another hospital that 
also received patients without medical records reported that in some cases, 
the medical records arrived several days after the patients.  One hospital 
that also received evacuating patients without medical records, or with the 
wrong records, attributed problems to miscommunication between the 
evacuating hospital and EMS (emergency medical services) who were 
responsible for transferring the patients. 
Hospitals reported challenges related to communication 
failures during the storm 
About one-third of hospitals in the declared disaster areas (59 of 172) 
reported that communication was a challenge during the storm, including 
contacting staff, officials, and other hospitals.  Sandy compromised cell 
phone towers, flooded telephone switching stations, and damaged 
telephone utility poles (see Box 1 for a description of one hospitals 
communication challenges during the storm).  Several hospitals reported 
that they subsequently developed multiple communication channels, such 
as using multiple cell phone providers, using satellite telephones, and 
installing a cell phone tower in the hospital that will be powered by a 
generator.    
  Box 1:  One Hospitals Communication Challenges During Sandy  
 
As Sandy made  landfall, administrators described how losing both landline and cell phone service became a 
major challenge to hospital operations during the storm.  You assume the back-up will work, but when the 
back-up does no t work what do you do?   
 
Throughout the s torm, the hospital had no contact with outside entities.  Although the only hospital in the 
community, neither city nor county  emergency managers provided the hospital with updates during or 
immediately afte r the storm.  Several years prior to Sandy, a Medical Command Center was established by  
the State to provide hospitals  with information about resources during a disaster.  However, this Medical  
Command Cente r became inoperable during Sandy because it did not have a backup system in place when 
power outages and communication failures struck the area.  
   
Administrators also reported that using two-way radios (walkie-talkies) for communicating within the hospital 
was difficult beca use they  did not have enough devices.  Therefore, hospital staff found themselves running 
up and down the hospital floors delivering messages and receiving updates.  
   
Source:  Summary of communication challenges reported to OIG by the hospital administrators. 
 
 
   
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Hospitals struggled to communicate with other hospitals and external 
entities.  Forty-seven hospitals reported challenges in communicating with 
other hospitals and external entities, such as local emergency management  
agencies, State and local health departments, and utility companies.  
Administrators from one hospital that received patients reported struggling 
to coordinate the transfer of patients with the evacuating hospital because  
of nonfunctioning communication systems.  Another hospital reported that 
it learned after the storm that other hospitals wanted to help, but were 
unable to contact the hospital to offer assistance.   
Hospitals also reported challenges with community 
collaboration over shared resources, such as fuel, 
transportation, hospital beds, and public shelters  
Of hospitals in declared disaster areas, 47 reported experiencing 
collaboration challenges with other entities, such as hospitals and local 
and State authorities, when responding to Sandy.  Many of these 
challenges were interrelated and included problems with distributing and 
sharing fuel, transportation, hospital beds, and space in public shelters, all 
of which affected the capability of hospitals to care for patients.   
Hospitals struggled to secure sufficient fuel supply, which affected all 
aspects of hospital operations, including staff availability. For  
29 hospitals, fuel shortage was a challenge that substantially affected 
patient care. Fuel needs included running backup generators, operating 
ambulances, ensuring delivery of supplies, and securing sufficient staffing 
levels. Although gasoline was often available, gas stations did not have 
backup generators to pump the gasoline when the main power went out.  
Administrators from one hospital reported that there was no community 
collaboration regarding fuel. Further, another hospital described how the 
hospital ran on backup generators for a week, in constant fear of running 
out of fuel, and was the last hospital in its State to get power back after the  
storm.    
For one hospital, fuel availability was the most significant factor to affect 
the sufficiency of staffing during the storm.  In this case and others, much-
needed hospital staff were unable to get to work because of fuel shortages.  
One-third of hospitals in declared disaster areas (57 of 172) reported 
staffing challenges, including shortages of clinical and nonclinical staff.  
According to hospitals, the State and  local authorities eventually arranged 
for doctors and nurses to receive priority in obtaining gasoline from the 
limited number of gas stations still functioning.  However, one hospital 
expressed that the arrangement to provide gasoline to essential staff should 
have come earlier.  Another hospital suggested that the prioritization of 
gasoline should have included more staff than just doctors and nurses, 
   
Hospital Emergency Preparedness and Response During Superstorm Sandy  (OEI-06-13-00260)   13 
 
   
   
given that many hospital staff, such as pharmacy staff, environmental 
services staff, and senior leadership, are essential to hospital operations.   
Public transit system and road closures affected hospital staffing.    
Fifteen hospitals reported transportation challenges as a result of Sandy.  
Road closures and inoperable public transit systems, in addition to fuel 
shortages, made it difficult for staff to get to work.  One hospital described 
how doctors tried to get to the hospital, but city and law enforcement staff  
turned them away because of road closures.  Administrators expressed the 
desire for hospital staff to be considered by community officials as 
emergency workers, such as first responders, allowing them privileged 
access to hospitals in affected areas.   
Hospitals encountered insufficient patient transportation. One hospital 
that partially evacuated stated that a full evacuation would have been 
impossible because it did not have enough ambulances.  In this case, each 
patient took approximately 3 hours to transfer to the receiving facility (see 
Figure 4 for a photo of an ambulance convoy during Sandy).  Another 
hospital reported that limitations in moving patients across State lines 
caused ambulances to travel greater distances under storm conditions.  For 
example, evacuating hospitals reported that they could transfer Medicaid 
patients across State lines only if the receiving hospital had assurance of 
reimbursement for those patients.  Without such limitations, the hospital 
could have transferred patients more quickly to nearby hospitals in its 
neighboring State, rather than tying up ambulances for 4-5 hours for each 
patient that instead had to be transported to hospitals at greater distances 
within the State.  
  Figure 4: Photo of an Ambulance Convoy During Sandy  
 
 
 
 
 
 
 
 
 
 
 
 
 
Photo courtesy of U.S. Air Force, Airman 1st Class, Matthew R. Throneberry.  Used with permission. 
   
Hospital Emergency Preparedness and Response During Superstorm Sandy  (OEI-06-13-00260)   14 
 
   
   
Differences in policies regarding evacuation procedures and patient care  
affected collaboration between hospitals and EMS. For five hospitals, 
collaboration with EMS was a challenge during the storm. One hospital 
described the logistics of evacuating patients as a nightmare in that EMS 
staff took control of the evacuation without input from the hospital.  For 
example, the hospital wanted to transport ventilator patients individually 
in ambulances, but the EMS provider placed them in ambulance buses 
with several other patients.  Additionally, EMS chose to put ventilator  
patients and other more acute patients in the back of the bus instead of the 
front, which meant that critical patients had to spend more time on the bus 
than the noncritical patients who were loaded last and unloaded first.  One 
hospital explained this collaboration challenge as a difference in 
philosophy about transfers: the hospital treated the transfer as a planned 
evacuation in which they use normal ambulance procedures, while EMS 
considered it an emergency evacuation in which they try to get everyone 
out as quickly as possible. 
Hospitals reported challenges with securing sufficient patient beds, 
particularly specialty beds. As Sandy swept across several States, 
hospitals began to compete for patient beds.  Eighteen hospitals reported 
experiencing challenges with patient bed shortages during the storm.    
One hospital described how specialty beds (e.g., intensive care) were 
particularly in demand.  Another hospital reported extreme difficulty 
finding beds appropriate for ventilator dependent patients and psychiatric 
patients.  Compounding this problem  were differences in bed type 
definitions across facilities.  For example, a hospital may state that it has 
an intensive care unit (ICU) bed available, but because definitions of ICU 
beds vary, the hospital may not be able to care for every type of ICU 
patient (e.g., neurosurgery patients).  Additionally, members of a health 
care coalition expressed concern about the lack of a bed-tracking 
mechanism that accounted for the type  of bed needed.  They reported that 
this caused an uneven distribution of patients across hospitals during the 
storm.  For example, one hospital responded to every bed request because 
it was unaware of availability in other hospitals.  Some hospitals attributed 
these challenges to unorganized or nonfunctioning ESF #8 coordination.  
According to these hospitals, the lack of a common operating system  
limited the communication between State and city government entities and 
consequently affected hospitals ability to effectively communicate their  
needs and availability during the storm.  
Hospitals faced a patient surge from other health care providers, not only 
other hospitals but also from clinics and physician offices. For  
74 hospitals in declared disaster areas, effectively handling patient surge 
was a substantial challenge (see Box 2 for a description of one hospitals 
   
Hospital Emergency Preparedness and Response During Superstorm Sandy  (OEI-06-13-00260)   15 
 
   
   
experience with patient surge during Sandy).  To make room for new 
patients during the storm, most hospitals (126) reported discharging 
patients whom staff had identified as safe for discharge.  However, for  
30 hospitals, discharging substantial numbers of patients was not feasible.  
One of these hospitals described how the surrounding area was flooded or 
was without power, including many patients homes.  The hospital 
reported that its patient numbers during Sandy were nearly 50 percent 
higher than normal, which required the hospital to open a closed unit.  
Another hospital reported that transportation problems inhibited 
discharging patients who were well enough to go home and had waiting 
caregivers and safe destinations. 
 
Box 2:  One Hospitals Patient Surge Experience During Sandy 
 
 
Administrators at one hospital that sheltered in place reported that when nearby hospitals evacuated, not  
only did the hospital receive many  of their patients but also their hospital became the only facility in the area 
 
capable of caring for trauma patients and non-urgent-care medical needs.  During the patient surge, which 
lasted 
 
4 months, the hospital received over 600 patients from other hospitals.   
 
 
To accommodate the patient surge, the hospital added beds in the emergency department, turned private 
patient rooms into semi-private rooms, converted the lobby into an inpatient care facility and nursing areas 
  into patient rooms, and set up tents outside the facility to treat patients.  Despite these efforts, administrators 
described how  the hospital struggled with not having sufficient patient beds and being over the Medicare-
  allowed patient capacity in the emergency  department throughout the storm.   
 
  The hospital also struggled to accommodate the unexpectedly  large number of staff and staff families who 
needed room and board after losing their homes and vehicles or who were unable to leave and return to 
  work because of fuel shortages, road closures, and public transit system shutdowns.  The hospital partnered  
with a nearby hotel to house some of its staff, while other staff slept on cots provided by the city.  
   
Source:  Summary  of patient surge description reported to OIG by the hospital administrators. 
 
Hospitals also reported a surge of patients from other health care providers 
during and in the aftermath of the storm because many community-based 
providers closed their facilities (see Figure 5).  In some cases, staff at 
health care clinics, such as dialysis centers, instructed patients to go to 
hospital emergency rooms.  In other cases, community members with 
chronic diseases, such as diabetes and hypertension, sought care because 
they ran out of medicine during the storm because of closures of 
pharmacies and doctors offices.  For one hospital, the closure of nearby 
methadone clinics and mental health clinics caused patients with drug 
abuse problems and mental illness to seek treatment at the hospital.  
According to this hospital, it treated three times the normal number of 
methadone patients during the storm.  Administrators also expressed 
concern about security, reporting that local police were unavailable to 
offer assistance.  During interviews, a State hospital association official 
reported that the closure of mental health clinics prevented patients from  
getting counseling, support, and medications during the storm, which has  
   
Hospital Emergency Preparedness and Response During Superstorm Sandy  (OEI-06-13-00260)   16 
 
   
   
 
resulted in an increase of psychiatric patients in hospitals since the storm.   
Figure 5: Hospitals With Patient Surge Challenges, by Surge Source, 
N=172  
  25% 
 
20% 
 
15% 
 
10% 
 
5% 
 
  0% 
 
 
 
 
 
Note: Some hospitals reported experiencing challenges with more than one  patient surge  source. 
Source:  OIG analysis of 172 hospital  questionnaire responses, 2013. 
Hospitals also functioned as community shelters, sometimes expending 
hospital resources for those without medical need.  When asked in the 
questionnaires what the communities could have done differently in 
responding to Sandy, 50 hospitals responded that their communities 
should have provided more shelters (medical and nonmedical) to the 
public. According to hospital administrators in one area, the county 
opened several public shelters but did not publicize them to the 
community.   
As a result of the limited number of medical shelters, 35 hospitals reported 
challenges with treating a surge of homebound community members.   
One of these hospitals described oxygen-dependent community members 
arriving at the emergency room immediately after Sandy made landfall 
because they needed electrical outlets for their oxygen tanks.   The hospital 
reported this surge as its most difficult problem during the storm because 
these individuals did not qualify for hospital admission on the basis of 
medical necessity, but consumed much of the hospitals resources in 
power and staffing.  For 18 hospitals, unbillable patient care was a 
challenge that hampered their recovery from the storm.   
Hospital Emergency Preparedness and Response During Superstorm Sandy  (OEI-06-13-00260)   17 
   
   
In some communities, hospitals also became a neighborhood sanctuary  
for community members who needed shelter but not medical care.  One 
hospital reported monitoring its electrical outlets to make sure that people 
did not use unnecessary power while the hospital was running on backup 
generators. Another hospital described the costly challenge of feeding the 
community and giving away large quantities of supplies during and in the 
immediate aftermath of the storm, purchased at full retail prices rather  
than wholesale prices, at the same  time it was losing revenue on canceled 
elective surgeries and outpatient services.   
Hospitals reported that prior emergency planning was 
valuable during the storm and that they subsequently  
revised their plans as a result of lessons learned 
All 172 hospitals reported participating in at least 1 emergency 
preparedness activity, such as a simulated disaster exercise or an actual 
response to an emergency, in the year prior to Sandy.  Hospitals reported 
that a diverse group of participants from the hospital were involved in 
these activities, including nursing, security, and emergency departments.  
Some hospitals credited the success of their responses to Sandy to 
participation in these emergency preparedness activities.  One 
administrator expressed how the hospital had drilled on a variety of 
emergency scenarios prior to Sandy, but Sandy was a storm of such 
magnitude that it constituted all the scenarios happening at once.  
Although, a causal link could not be made between the challenges 
experienced by hospitals during Sandy and their emergency planning prior 
to the storm, most of the hospitals (16 of 19) that reported not 
experiencing any substantial challenges attributed their lack of problems 
to successful emergency planning.   
Regarding support received in the year prior to Sandy, 143 hospitals 
reported receiving support through ASPRs Hospital Preparedness 
Program and 52 hospitals received support through CDCs Public Health 
Emergency Preparedness Cooperative Agreements Program.  Most of this 
support was in the form of supplies and equipment (e.g., stretchers, cots, 
and cell phones). Support also came in the form of funding for disaster 
training and drills, such as sponsoring regional exercises, and disaster 
planning guidance. One hospital administrator noted that the availability 
of ASPRs Hospital Preparedness Program funds provided incentives for 
the hospital to invest in emergency preparedness and build relationships 
with other facilities. 
   
Hospital Emergency Preparedness and Response During Superstorm Sandy  (OEI-06-13-00260)   18 
 
 
 
   
   
Hospitals reported that emergency plans were useful during the 
storm, but they identified opportunities for improvement  
All but 1 of the 172 hospitals reported that their written emergency plans 
were useful during Sandy.  Most hospitals (117 of 172) attributed this to 
the plans being current and accessible to staff, and staff were generally 
trained on the plans. Hospitals also cited useful factors, such as plans that 
specifically addressed hurricanes or were designed for all hazards.  The 
single hospital reporting that its plan was not useful noted that it 
restructured the plan and enhanced its exercises as a result of Sandy. 
In total, 139 hospitals reported making changes to their plans following 
Sandy.  Examples of changes included planning for emergencies of longer 
duration and more clearly defining staff roles during the emergency. In 
discussing their hospital response to Sandy, administrators at several 
hospitals reported they found, during the storm, that key staff roles were 
unassigned. These administrators identified a need for additional training 
of staff in leadership roles and for frontline staff to be well-versed in the 
hospital emergency plan.  Another hospital developed a pre-storm  
checklist for each department, including administration, clinical 
laboratory, and facilities.  The checklist breaks down tasks according to 
projected time of storm impact and includes verifying available 
equipment, notifying staff and local authorities, and ensuring adequate 
supplies (such as food, linens, and flashlights). 
Prior to the storm, most hospitals received 
emergency-related deficiency citations from hospital 
surveyors  
During the most recent survey conducted prior to Sandy, surveyors cited 
157 of 171 hospitals in declared disaster areas for deficiencies related to 
emergency preparedness and response.  These deficiencies made up one-
fourth of all deficiencies cited during the surveys (775 of 3,063 deficiency 
citations).  While some of these deficiencies related to the challenges 
experienced by hospitals during the storm, other deficiencies did not relate 
but could affect hospitals  ability to respond to a major disaster.  Taken as 
a whole, the deficiency citations appear to demonstrate that surveyors 
review hospital operations relevant to emergency preparedness.  
Hospitals received deficiency citations related to many of the 
issues administrators identified as challenges during Sandy 
Deficiencies that related to emergency preparedness and response 
   
Hospital Emergency Preparedness and Response During Superstorm Sandy  (OEI-06-13-00260)   19 
 
 
 
   
   
reflected a broad range of issues; 60 hospitals had deficiencies related to 
challenges identified by hospitals during Sandy.  
Utility systems found deficient, such as routine testing of generators. 
Surveyors cited 47 hospitals for emergency deficiencies that related to 
their utility systems, a prominent challenge reported by hospitals during 
Sandy.  Many of these deficiencies involved infrequent testing or incorrect 
testing of the hospital backup generator.  Other deficiencies related to 
infrequent testing or lack of emergency lighting systems.  As noted earlier,  
69 hospitals reported challenges with their electrical utilities that either 
required use of emergency power or placed them at risk of requiring its 
use. 
Emergency planning found deficient, such as conducting adequate 
emergency drills. Surveyors cited 23 hospitals for deficiencies related to 
emergency planning and drills.  Several hospitals were cited for not 
specifying in their bylaws which staff were responsible for granting 
physician privileges during disasters or not requiring valid identification 
for volunteer practitioners. Surveyors also cited hospitals with 
deficiencies for failing to follow required procedures in conducting 
emergency drills.  Some of these deficiency citations were directly related 
to preparation for major disasters, such as Sandy.  For example,  
one hospital with emergency drill deficiency citations did not include a 
simulation of patient surge, which corresponds to the second most-
reported challenge among hospitals during Sandy.  Another hospital 
received deficiency citations on the survey prior to Sandy for not 
establishing a sustainability plan when the hospital cannot be supported by 
the local community, such as instances when vendors are unable to 
provide the hospital with necessary supplies and equipment. 
Hospitals also received deficiencies for other emergency-
related issues, such as fire safety and obstruction 
Surveyors cited 156 hospitals for deficiencies that were not identified as 
challenges during Sandy but covered other issues related to emergency 
preparedness and response. These deficiencies largely concerned fire 
safety, obstruction, and signage, which could affect the ability of hospitals 
to evacuate or receive patients during a major disaster.  Issues such as 
improper hospital signage could have serious implications during 
disasters, including impeding evacuation and hampering navigation for 
visiting staff who are evacuating to receiving hospitals and are not familiar 
with the surroundings. 
   
Hospital Emergency Preparedness and Response During Superstorm Sandy  (OEI-06-13-00260)   20 
 
 
 
   
   
Fire safety deficiencies mostly addressed equipment problems. Surveyors 
cited 144 hospitals for deficiencies that concerned fire safety.  A major 
portion of the Medicare Condition of Participation pertaining to physical 
environment assesses hospital compliance with fire safety requirements.  
Numerous hospitals received deficiency citations related to fire safety 
equipment (e.g., rooms not equipped with smoke detectors, inaccessible 
fire extinguishers, and obstructed sprinkler heads).  Other examples of 
deficiencies that could result in problems in a fire included nonlatching 
smoke barrier doors and fire resistant walls not properly sealed with  
fire-resistant material.  
Obstruction of hospital exits cited as deficiencies. Surveyors cited 
82 hospitals for deficiencies related to obstructions to exits or exit routes.  
For example, surveyors found medical equipment and furniture that 
blocked corridors that would be used to exit the building.  Surveyors also 
cited hospitals for exit doors that either failed to open or were locked and 
required a code or badge to open. 
Misleading or missing hospital signage cited as deficiencies. Surveyors 
cited 50 hospitals for deficiencies related to insufficiencies with hospital 
signage. For example, numerous hospitals were cited for not posting No 
Exit signs on passages that could be mistaken for exits.  One hospital was 
cited for posting an Exit sign directing people into a hazardous storage 
area and another for posting an Exit sign directing people out onto the 
roof. Surveyors also cited hospitals for not posting Exit signs on actual 
exit routes. Additionally, surveyors cited hospitals for not having signs 
identifying the story of each stairwell landing.   
 
 
 
 
 
 
 
 
 
   
Hospital Emergency Preparedness and Response During Superstorm Sandy  (OEI-06-13-00260)   21 
 
 
 
   
   
CONCLUSION AND RECOMMENDATIONS  
The strength of Sandy and widespread flooding along the coastal areas 
placed high demands on affected hospitals and related services.  While 
facing challenges created by the storm, hospital operations were highly 
vulnerable to breakdowns. These challenges, along with emergency-
related survey deficiencies, revealed  gaps in planning and execution that 
might be applicable to hospitals nationwide.  Improvements are needed in 
hospital planning and infrastructure, community-wide collaboration, and 
access to resources.  These improvements will require targeted 
adjustments in Federal coordination and oversight. 
Therefore, we recommend the following: 
ASPR should continue to promote Federal, State, and 
community collaboration in major disasters 
ASPR has a role in ensuring that hospitals practice effective emergency 
management through the Hospital Preparedness Program, but insufficient 
community-wide coordination among affected entities was a common 
thread through the challenges identified by hospital administrators.  ASPR 
should encourage awardees of the Hospital Preparedness Program to 
prioritize exercises for communities and health care coalitions that include 
hospitals, long-term care facilities, EMS, emergency management, public 
health, and other essential partners.  Exercises should address patient and 
medical surge and failures of key resources (e.g., power, emergency 
generator, and primary and secondary communication devices).  ASPR 
should also provide guidance to communities and health care coalitions to 
strengthen information sharing and enhance interoperable communication 
capabilities. The guidance should emphasize the importance of 
conducting exercises and establishing plans that address centralizing 
coordination of evacuations, tracking patients and beds (e.g., identifying 
specialty beds), setting up medical and nonmedical shelters, identifying 
community members with special needs (e.g., oxygen-dependent 
individuals), and coordinating requests for assistance (e.g., fuel, staff 
transportation).  
CMS should examine existing policies and provide guidance 
regarding flexibility for reimbursement under disaster 
conditions  
During large-scale disasters, such as Sandy, access to medical needs 
shelters may be insufficient to meet the ongoing medical care of some  
Medicare and Medicaid beneficiaries.  CMS should examine the existing 
medical necessity criteria for Medicare and Medicaid reimbursement 
   
Hospital Emergency Preparedness and Response During Superstorm Sandy  (OEI-06-13-00260)   22 
 
 
 
   
   
during disasters, to allow hospitals greater flexibility to provide medical 
care to individuals who under normal circumstances do not meet the 
criteria for hospital admission (e.g., oxygen-dependent individuals).  CMS 
should also provide guidance to hospitals regarding Medicare and 
Medicaid reimbursement when receiving patients from other States, to 
improve the coordination of patient evacuations.  Because of confusion 
over reimbursement for care of Medicaid patients transported across State 
lines, at least one hospital instead had to transfer patients greater distances 
to different hospitals within the State. 
Additionally, CMS should develop guidance to hospitals to ensure that 
they can meet patient surge from evacuating hospitals and surrounding 
communities.  For example, guidance could include drills and exercises 
focusing on short-term and long-term patient surge, planning for 
additional supplies and equipment, and accessibility to vendors and 
resources during disasters.  Further, CMS should include additional 
guidance on the Medicare Conditions of Participation focused on 
sufficiency and training of medical staff, to prepare them for maintaining  
patient care during extended periods of poor conditions, including loss of 
power, technology, and equipment.   
 
 
 
 
 
 
 
 
 
 
 
 
 
   
Hospital Emergency Preparedness and Response During Superstorm Sandy  (OEI-06-13-00260)   23 
 
 
 
   
   
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL  
RESPONSE 
We received comments on the draft report from  ASPR and CMS. 
ASPR concurred with our recommendation to continue promoting Federal, 
State, and community collaboration in preparing for, responding to, and 
recovering from disasters.  ASPR stated that it will continue to provide 
technical assistance to support the growth of health care coalitions to 
enhance community resilience. ASPR stated that through the health care 
coalitions and the Hospital Preparedness Program, it will address the 
challenges identified in this report.  Further,  ASPR outlined several 
initiatives that are underway that will support collaboration among 
Federal, State, and community entities, including a technical assistance 
center where stakeholders can share best practices and lessons learned and 
tools for assessing communities and hospitals capabilities in responding  
to medical surge and rapid influx of patients during a disaster. 
CMS concurred with our recommendation to examine existing policies 
and provide guidance regarding flexibility for reimbursement under 
disaster conditions. CMS described several existing statutory and 
regulatory provisions that authorize the Secretary to waive or modify 
program rules in an emergency and during an emergency period.  
However, CMS stated that at this time, Medicare has no statutory authority 
that would afford hospitals flexibility to bill for medical care to patients 
who would not normally meet the criteria for hospital services.  In 
response to our recommendation about providing guidance, CMS 
referenced the proposed rule that would establish national emergency 
preparedness requirements for providers and suppliers participating in 
Medicare and Medicaid.31  CMS also stated that once the proposed rule is 
finalized, it will issue revised interpretive guidance to health care 
providers and suppliers that will explain in detail the new requirements 
and address issues identified in this report. 
For the full text of ASPRs and CMSs comments, see Appendix C.   
 
 
____________________________________________________________ 
31 78 Fed. Reg. 79082-79200 (Dec. 27, 2013). 
   
Hospital Emergency Preparedness and Response During Superstorm Sandy  (OEI-06-13-00260)   24 
 
 
 
   
   
APPENDIX A 
METHODOLOGY 
This study describes disaster experiences of Medicare-certified, short-term 
acute care hospitals located in the 40 counties in Connecticut, New Jersey,  
and New York that received disaster declarations as a result of Sandy.  
This study also examines emergency-related deficiencies cited to these 
hospitals by State survey agencies and accreditation organizations prior to  
the storm.  
Data Collection 
Hospital Questionnaires    
We administered electronic questionnaires to 174 hospitals located in the 
federally declared disaster areas (see Figure A-1 for a map of the hospitals 
located in the affected areas).32  The hospital officials responded between 
July  October 2013. Questions focused on: 
	   hospital disaster responses, that is whether they evacuated, partially 
evacuated, or sheltered in place during the storm;33  
	   decisions hospitals made regarding evacuating, sheltering in place, or 
receiving evacuated patients; 
	   factors that impeded or enhanced their ability to execute evacuation 
plans; 
	   problems, if any, related to the health and safety of patients during the 
storm;  
	   assistance, if any,  provided to hospitals by State survey agencies and 
accreditation organizations to ensure hospital compliance during and 
after the storm;   
	   coordination with State and local emergency management agencies 
during the storm; and 
	   participation in ASPRs Hospital Preparedness Program and CDCs 
Public Health Emergency Preparedness Cooperative Agreements 
program. 
____________________________________________________________ 
32  We identified  hospitals located in declared disaster areas using CMS data from  
Medicare Hospital Compare and CASPER. 
33 For the purposes of this evaluation, we  defined hospitals as sheltering in  place if they 
did not evacuate or partially evacuate. 
   
Hospital Emergency Preparedness and Response During Superstorm Sandy  (OEI-06-13-00260)   25 
 
 
 
   
   
We received questionnaire responses from 172 of the 174 hospitals.   
 
Figure A-1: Map of Hospitals Located in Federally  Declared Disaster Areas in Connecticut, New  
Jersey, and New  Yo rk as a Result of Sandy 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Source:  OIG analysis of CMS data from Medicare Hospital Compare and CASPER, 2013; and FEMA, FEMA-4085-DR, FEMA-4086-DR, and FEMA-
 
4087-DR.  Accessed at http://www.fema.gov  on March 4, 2013.  
 
Interviews  
Hospital Site Visits and Interviews. To learn about the experiences of 
hospitals located in areas most affected by the storm, we conducted site 
visits during August 2013 to a small, purposive subset of 10 hospitals, and 
   
Hospital Emergency Preparedness and Response During Superstorm Sandy  (OEI-06-13-00260)   26 
 
 
 
   
   
interviewed hospital administrators and staff.34 Interview questions 
focused on emergency preparedness; decisions to evacuate, shelter in 
place, or receive evacuated patients; experiences during and after the 
disaster; and adherence to emergency plans.  We also asked about lessons 
learned from the disaster experience and asked whether hospitals had 
made changes to their emergency plans and training as a result.   
State Survey Agencies and Accreditation Organizations. To gain insight 
about State-level collaboration, assistance, and regulations related to 
hospital emergency preparedness and response, we conducted telephone 
interviews with State survey agencies in Connecticut, New Jersey, and 
New York, as well as the three accreditation organizations that had 
surveyed hospitals in the affected areas, TJC, AOA, and DNVHC.35   We  
asked about the processes surveying entities used to ensure that hospitals 
comply with Federal regulations regarding emergency preparedness and 
training, as well as any assistance provided to hospitals prior to, during, 
and after the storm.   We also asked about lessons learned from the disaster 
experience and asked whether State survey agencies and accreditation 
organizations had made changes to their policies and procedures for 
hospitals as a result. 
State Hospital Associations.  We also conducted telephone interviews with 
State hospital associations in Connecticut, New Jersey, and New York to 
gain insight about State-level collaboration, assistance, and regulations 
related to hospital emergency preparedness and response.  Interview 
questions focused on requirements, support and assistance, and 
communication and collaboration with hospitals for emergency 
preparedness planning prior to the disaster.  We also asked about lessons 
learned and asked whether State hospital associations had made changes to 
their plans for hospitals as a result.   
State Health Care Coalitions. To gain insight about the role and 
collaboration of health care coalitions regarding emergency preparedness 
and response, we conducted telephone interviews with State health care 
coalitions in Connecticut, New Jersey, and New York.  We asked about 
assistance provided prior to, during, and after the disaster.  We also asked 
about lessons learned from the disaster experience and asked whether 
____________________________________________________________ 
34  We  purposively selected hospitals that evacuated, partially evacuated, sheltered in  
place, and/or received patients from other hospitals and were located in areas most 
affected by Sandy.  
35 The Center for Improvement in Healthcare Quality was approved by CMS as a national 
accrediting organization on July 26, 2013, after our study period.  78 Fed. Reg. 45231, 
Federal  Register, Vol. 74, Issue 144 (July  26, 2013).   
   
Hospital Emergency Preparedness and Response During Superstorm Sandy  (OEI-06-13-00260)   27 
 
 
 
   
   
health care coalitions had made changes to their guidance provided to 
hospitals as a result.  Additionally, we asked about participation in ASPRs 
Hospital Preparedness Program. 
Document Reviews  
Hospital After-Action Reports. For each of the 10 hospitals that we 
visited, we requested and received Sandy-specific after-action reports.  
These reports typically describe a hospitals actions taken before, during 
and after an event such as Sandy; evaluation of the hospitals actions; and 
any changes that the hospital will make to plans, policies, procedures, staff  
training, and physical environment to improve and enhance the hospitals 
response to a future event. 
Accreditation Organizations Documents. For each accreditation 
organization with which we conducted an interview, we also requested 
and received copies of documents detailing processes used to evaluate 
hospital emergency preparedness and training, such as survey protocols 
and guidelines. 
Hospital Surveys. For each of the 174 hospitals, we requested the most 
recent full standard survey conducted prior to the storm.36  Full standard 
surveys included surveyor notes, which provided specific details about 
each deficiency citation.   We received full surveys for 171 hospitals from  
TJC, AOA, DNVHC, and the Connecticut State survey agency.37 
  ____________________________________________________________ 
36  We  did not include complaint surveys in  our analysis.  Complaint surveys focus on the 
specific regulatory requirements related to the complaint.  During a complaint survey, if 
surveyors identify significant problems, the surveyors can expand the survey to review  
the hospitals compliance with  other Medicare Conditions  of Participation.  CMS, State 
Operations Manual, ch. 5,   5050 and 5200.1.  
37 The accreditation organizations surveyed  170 of the 171 hospitals in declared disaster 
areas.  TJC surveyed 163 hospitals, DNVHC surveyed  5  hospitals, and  AOA surveyed  2 
hospitals.  The  Connecticut State survey agency surveyed the remaining hospital.  We did  
not receive surveys for three hospitals because of unavailable data.  
   
Hospital Emergency Preparedness and Response During Superstorm Sandy  (OEI-06-13-00260)   28 
 
 
 
   
   
Data Analysis  
Qualitative analysis  
To examine challenges experienced by hospitals during Sandy, we 
qualitatively analyzed hospital questionnaire responses and transcripts 
from interviews with hospital staff,  State survey agencies, accreditation 
organizations, State hospital associations, and State health care coalitions.  
In analyzing the interview data, we developed themes and selected 
examples for illustration.  
Quantitative analysis    
We also analyzed hospital questionnaire responses and hospital deficiency 
data quantitatively.   Whenever possible, we quantified data from site visit 
interviews and hospital after-action reports.  To determine the prominence 
of emergency-related issues among hospital deficiencies, we reviewed full 
standard surveys and identified deficiencies related to emergency 
preparedness. To make these determinations, we reviewed surveyors  
written narratives of the circumstances leading to the deficiencies and their 
categorization of each deficiency to determine what the nature of the 
deficiency was and whether the problem identified by surveyors appeared 
relevant to emergency preparedness.   
 
 
 
 
 
 
 
 
 
 
 
 
 
   
Hospital Emergency Preparedness and Response During Superstorm Sandy  (OEI-06-13-00260)   29 
 
 
 
   
   
APPENDIX B 
Table B-1: Challenges Reported by Hospitals   
Hospitals 
Challenge  
(n=153)  
Hospital infrastructure    83 
     Electrical utilities  69 
     Backup generator   35 
     Structural damage   29 
Flooding   18 
     Water utilities   7 
     Gas utilities   3 
Building security  3 
Steam   2 
Patient surge   74 
     Patient surge from other hospitals  36 
     Patient surge from home care (chronic care)   35 
     Patient surge from nursing homes  32 
     Patient surge from clinics, such as dialysis and methadone clinics  30 
     Patient surge from mental health clinics  4 
     Patient surge from shelters   3 
     Surge of nonmedical displaced persons   1 
Communication  59 
     Communication with staff who were off work   25 
     Communication with local authorities responsible for emergency management   23 
     Communication with utility companies  22 
     Communication within the hospital  20 
     Communication with other hospitals  18 
     Communication with State and local health departments   13 
     Communication lost  5 
Staffing   57 
     Nurse shortage   43 
     Physician shortage   13 
     Maintenance staff shortage   9 
     Dietary staff shortage   9 
     Security staff shortage   7 
     Problems managing volunteers and staff from other hospitals  4 
     Long work hours  2 
     Lab staff shortage  1 
     Documentation staff shortage   1 
     Support services  1 
     Housing arrangements for staff   1 
    Note: Some hospitals reported experiencing more than one challenge.                   Continued on next page. 
    The table represents only those hospitals that  reported one or more challenges. 
     
   
   
   
Hospital Emergency Preparedness and Response During Superstorm Sandy  (OEI-06-13-00260)   30 
 
 
 
   
   
Table B-1: Challenges Reported by Hospitals  
(Continued) 
Hospitals 
Challenge  
(n=153)  
Recovery    50 
Financial loss  44 
     Physical damage to hospital  26 
Unbillable patient care   18 
     Decreased census after the storm  15 
     Increased staff mental and physical health issues (including stress and PTSD)   15 
     Damage to medical equipment  9 
Loss of medical equipment  8 
     Damage to computer and other health information systems  7 
     Decreased staff productivity   7 
     Problems with returning to the facility after the storm   6 
Personal impact on staff  5 
     Shift of patient diagnostic mix  4 
     Increased rates of sick leave   3 
     Increased staff turnover rates after the storm   1 
     Increased census  1 
Supplies   47 
Fuel   29 
Pharmaceutical supplies  10 
     Food and water   9 
Linen  6 
Medical equipment (including furniture)   5 
Collaboration   47 
     Collaboration with local authorities responsible for emergency management   27 
     Collaboration with State authorities responsible for emergency management   22 
     Collaboration with utility companies  11 
     Collaboration with other hospitals  9 
     Collaboration with State and local emergency response entities (EMS)  5 
     Collaboration with Federal authorities responsible for emergency  management   3 
Patient care   42 
Patient discharge   30 
     Patient transfer  18 
     Shortage of patient beds  18 
     Shortage of psychiatric beds   3 
     Shortage of pediatric patient beds  1 
Tracking evacuated patients   1 
     Informing families/guardians of evacuated patients location   1 
     Delayed lab results  1 
Transportation   15 
Note: Some hospitals reported experiencing more than one challenge.                   Continued on next page. 
The table represents only those hospitals that  reported one or more critical challenges. 
 
 
   
Hospital Emergency Preparedness and Response During Superstorm Sandy  (OEI-06-13-00260)   31 
 
 
 
   
   
Table B-1: Challenges Reported by Hospitals  
(Continued) 
Hospitals 
Challenge  
(n=153)  
Documentation   13 
     Access to patient medical records   7 
     Incompatibility of medical record system with other systems   3 
     Credentialing and privileging of medical staff   2 
     Less efficient downtime process   1 
Medicare Conditions of Participation (CoP)   5 
     CoPs related to patient care   3 
     CoPs related to the hospital physical plant   2 
     CoPs related to communication  1 
     CoPs related to patient care   1 
Note: Some hospitals reported experiencing more than one challenge. The table represents only  those hospitals 
 
that reported one or more critical challenges. 

Source: OIG analysis of 172 hospital questionnaire responses, 2013. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
Hospital Emergency Preparedness and Response During Superstorm Sandy  (OEI-06-13-00260)   32 
 
 
 
   
   
APENDIX C 
Agency Comments:  ASPR 
 
   
Hospital Emergency Preparedness and Response During Superstorm Sandy  (OEI-06-13-00260)  33 
 
 
 
   
   
ASPR (continued) 
 
 
   
Hospital Emergency Preparedness and Response During Superstorm Sandy  (OEI-06-13-00260)  34 
 
 
 
  ASPR (continued) 
OEI-06-13-00260 
Page 3 
public health activities. The initiative will also in FY 2015 launch anonymous data and mapping 
tools that can inform and assist public health, emergency management, healthcare coalitions, and 
other community partners with emergency planning and exercises. The project will enable 
emergency management, public health, and medical care providers to identify critical 
infrastructure, planning, exercising, and allocation of key resources capabilities required for 
medical Slll"ge. 
During FY 2014, ASPR also sponsored the development ofa Hmpital Surge Stress Test Tool 
that hospitals can usc to test and evaluate their ability absorb a sudden influx of patients that 
would exceed their normal patient surge capacity. The purpose of the tool is to mimic the effect 
that a mass casualty effect has on a hospital's emergency department and inpatient wards and the 
ability absorb and move patients during the first 90 to 120 minutes of an event. Because mass 
casualty events exceed 90 minutes, hospitals have and will be forced to address increased 
demand for bed space through various tactics such as cancellation ofelective surgeries and rapid 
release oflower acuity patients. ASPR is cunently developing a new stand-alone Healthcare 
Coalition Module that, when used in concc1i with the Hospital Surge Stress Test Tool fully 
engages and enables hcalthcare coalition (HCC) members (e.g., hospitals, long-term care, 
dialysis centers, community health centers, public health, emergency medical services, 
emergency management, or other fom1al/infom1al regional coordinating entities) to participate in 
an exercise, and all follow-up evaluation and measurement activities. The goal is to develop a 
stand-alone IICC Surge Stress Test Tool or module (e.g. HCC Module) that will allow hospitals 
and HPP-fundcd coalitions to test and evaluate their ability to respond to a large and sustained 
mass casualty event. The HCC Stress Test Too/must be able to test the HCCs' ability to: 
 	 activate and communicate among its members based on established protocols and 

doctrine; 

 	 implement components described in the HPP Jiealthcare Preparedness Capabilities, 
National Guidance .for Healthcare System Preparedness; and 
 	 assess the HCCs ability to execute all three pillars oflmmediate Bed Availability (IBA), 
including (I) situational awareness, (2) onboarding ofpatients and (3) oftloading of 
patients. 
Thank you again for can-ying out this study. The findings of this OIG study highlight the 
urgency and essential nature ofASPR's efforts to promote federal, state and community 
collaboration so that hospitals and health care communities arc truly prepared, and field tested, to 
respond effectively to disasters. This study provides a snapshot of!cssons learned from 
hospitals' response to Sandy that will be a valuable addition to the knowledge base. We 
appreciate the oppmiunity to review your report and respond to your recommendation. Please 
direct any questions to Marion Aldlich by telephone at 202.205.6053, or by e-mail at 
Marion.Aldrich@hhs.gov. 
------------------
Nicole Lurie, MD, MSPH 
Assistant Secretary tor Preparedness and Response 
Hospital Emergency Preparedness and Response During Superstorm Sandy (OEI-06-13-00260)  35  Agency Comments:  CMS 
.~~"~ 
(-:/- DEPARTMENT OF HEALlli & HUMAN SERVICES  Centers for Medicare & Medicaid Services 
Administrator 
Washington, DC 20201 
DATE:  JUL 17 2014 
TO: 	 Daniel R. Levinson 
!nspec\\lr General 
FROM: 	 M<r{ilyn 1'\avenner 
AdminiStrtltor 
SUBJECT: 	 Office oflnspector General (OIG) Draft Report: Hospital Emergency Preparedness 
and Response During Superstorm Sandy (OEI-06-13-00260) 
Thank you for the opportunity to review and comment on the above-subject OIG draft. The 
objective ofthis study was to describe the disaster experiences of hospitals affected by 
Superstorm Sandy, including challenges to hospital operations and patient care, and to determine 
the extent to which state survey agencies and accreditation organizations cited hospitals with 
emergency preparedness-related deficiencies prior to Superstorm Sandy. 
The OIG recommendation and the Centers for Medicare & Medicaid Services' (CMS) response 
are discussed below. 
OIG Recommendation 
The OIG recommends that CMS should examine existing policies and provide guidance 
regarding flexibility for reimbursement under disaster conditions. 
CMS Response 
The CMS concurs with the recommendation. CMS appreciates OIG's interest in seeing 
Medicare and Medicaid afford hospitals some flexibility in disaster situations in meeting medical 
necessity requirements in order to bill for medical care furnished to patients who would not 
normally meet the criteria for hospital services.  However, with regard to payment for services 
provided to Medicare beneficiaries, at this time, Medicare has no statutory authority to make the 
requested exceptions. In fact, very few program rules can be waived or modified under current 
law, even in a disaster or emergency. Section 1135 of the Social Security Act (the Act) 
authorizes the Secretary of the Department of Health and Human Services to waive, or in some 
cases, modify certain requirements that relate to the Medicare, Medicaid, and Children's Health 
Insurance Programs. The requirements that the Secretary may waive or modify, in an emergency 
area and during an emergency period, are, in summary, as follows: 
1.  Provider requirements: 
a. Conditions of participation or other certification requirements for an individual 
health care provider or types of providers and certain suppliers; 
Hospital Emergency Preparedness and Response During Superstorm Sandy (OEI-06-13-00260)  36   
   
CMS (continued) 
 
 
 
 
   
Hospital Emergency Preparedness and Response During Superstorm Sandy  (OEI-06-13-00260)  37 
 
 
 
   
   
CMS (continued) 
 
 
 
   
Hospital Emergency Preparedness and Response During Superstorm Sandy  (OEI-06-13-00260)  38 
 
 
 
   
   
ACKNOWLEDGMENTS 
This report was prepared under the direction of Kevin K. Golladay,  
Regional Inspector General for Evaluation and Inspections in the Dallas 
regional office; Ruth Ann Dorrill, Deputy Regional Inspector General; and 
Blaine Collins, Deputy Regional Inspector General.  
Petra Nealy served as the primary team  leader for this study.  Other Office  
of Evaluation and Inspections staff from the Dallas regional office who 
conducted the study include team leaders Deborah Cosimo and Lyndsay 
Patty and lead analyst Jennifer Hagen.  Additional Dallas regional office 
staff who contributed to the study include Ben Gaddis, Malinda Hicks, and 
Jeremy Moore.  Central office staff who provided support include 
Clarence Arnold and Meghan Kearns.  
 
   
Hospital Emergency Preparedness and Response During Superstorm Sandy  (OEI-06-13-00260)   39 
 
 
 
   
Office of Inspector General
http://oig.hhs.gov  
 
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 Services 
The Office  of  Audit Services  (OAS) provides auditing services  for HHS, either by  conducting  
audits  with its own audit resources or by  overseeing  audit 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 assessments help reduce waste, abuse, and  
mismanagement and promote economy and efficiency  throughout  HHS. 
Office of Evaluation and Inspections 
The Office  of  Evaluation and Inspections (OEI)  conducts national evaluations to  provide 
HHS, Congress, and the public with timely, useful, and reliable 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 Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations  
of  fraud and misconduct  related to HHS programs, 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 Inspector General 
The Office of Counsel to the  Inspector  General (OCIG) provides general legal services to 
OIG, rendering  advice and opinions on HHS programs and operations and  providing all  
legal support for OIGs  internal operations.  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.