Department of Health and Human Services

OFFICE OF 

INSPECTOR GENERAL 

N H E
URSING  OME  MERGENCY 

P R
REPAREDNESS AND  ESPONSE 

D R H
URING  ECENT  URRICANES

Daniel R. Levinson

Inspector General 

August 2006

OEI-06-06-00020
 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 all 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.  Specifically, these evaluations focus on preventing fraud, waste, or 
abuse and promoting economy, efficiency, and effectiveness in departmental programs.  
To promote impact, the reports also present practical recommendations for improving 
program operations. 
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative 
investigations of allegations of wrongdoing in HHS programs or to HHS beneficiaries 
and of unjust enrichment by providers.  The investigative efforts of OI lead to criminal 
convictions, administrative sanctions, 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 in OIG's internal operations. OCIG imposes program exclusions and civil 
monetary penalties on health care providers and litigates those actions within HHS. 
OCIG also represents OIG in the global settlement of cases arising under the Civil False 
Claims Act, develops and monitors corporate integrity agreements, develops compliance 
program guidances, renders advisory opinions on OIG sanctions to the health care 
community, and issues fraud alerts and other industry guidance.    E X E C U T I V E   S U M M A R Y  

OBJECTIVES 
1.	 To determine the national and Gulf State incidence of nursing 

home deficiencies for lack of emergency preparedness. 

2.	 To examine the experiences of selected Gulf State nursing homes 
during recent hurricanes. 
3.	 To review the emergency preparedness plans of selected Gulf State 
nursing homes and evaluate nursing home use of plans. 
BACKGROUND 
Federal law requires that Medicare and Medicaid-certified facilities 
have written plans and procedures to meet all potential emergencies 
and provide training to employees in emergency procedures.  State 
surveys assess whether facilities meet these requirements.  Four of the 
five Gulf States also have additional emergency preparedness 
requirements which are typically expected to be included in facility 
emergency plans.   
For this study, we reviewed State survey data for emergency 
preparedness measures both nationally and for Gulf States (Alabama, 
Florida, Louisiana, Mississippi, and Texas) and visited selected 
communities to interview nursing home staff, local authorities, and 
other stakeholders.  We also compared emergency plans for 20 selected 
nursing homes affected by hurricanes in the 5 Gulf States against a list 
of suggested provisions compiled from all Gulf State requirements and 
guidance, a variety of published works from authoritative sources such 
as the American Journal of Public Health, and other health care, elder 
care and emergency preparedness experts.   
FINDINGS 
Nationwide, 94 percent of nursing homes met Federal standards for 
emergency plans and 80 percent for sufficient emergency training in 
2004-2005; compliance rates were similar for Gulf States. Among 
Gulf States, 94 percent of nursing homes met standards for planning 
and 79 percent met standards for emergency training of staff.  
Multiple factors, including community evacuation orders, influenced 
the decision of selected nursing homes to evacuate or shelter. 
Nursing home administrators and owners most often made the decision 
to evacuate or shelter in place, using information from local authorities 
  OEI-06-06-00020  NURSING HOME EMERGENCY PREPAREDNESS AND RESPONSE DURING RECENT HURRICANES  i  E X E C U T I V E   S U M M A R Y  
and their own past experiences.  Mandatory evacuation orders had a 
strong influence on the decision to evacuate, but administrators and 
owners considered other factors as well, including the health of 
residents, risks of transporting, and availability of host facilities. 
All 20 of the selected Gulf State nursing homes experienced 
problems, whether they evacuated or sheltered in place. In some 
cases, problems can be tied to a lack of effective emergency planning or 
failure to properly execute the emergency plans. In others, the 
circumstances of the hurricane and its effect on resources were such 
that prior planning may not have anticipated the specific problems 
encountered, and impromptu decisions and actions were required.  
Similar problems emerged for evacuated facilities across States and 
communities, including transportation contracts that were not honored, 
lengthy travel times, complicated medication needs, host facilities that 
were unavailable or inadequately prepared, inadequate staffing, 
insufficient food and water, and difficult reentry to facilities. 
Administrators from 5 of the 13 selected nursing homes that evacuated 
reported a negative impact on resident health, such as dehydration, 
depression, and skin tears.  Facilities that sheltered in place 
encountered fewer problems, but still reported difficulty maintaining 
staffing, supplies, and facility services, and, as with the evacuated 
facilities, some additional problems were narrowly averted. 
Administrators and staff from selected nursing homes did not 
always follow emergency plans and plans often lacked suggested 
provisions. Each of the 20 emergency plans reviewed met Federal 
requirements on the most recent State survey.  However, 
administrators from 5 of the 20 facilities reported that they deviated 
from or worked beyond their emergency plans during the recent 
hurricanes, either because the plans were not updated or plans did 
not include instructions for particular circumstances.  When 
comparing details of their plans to their reported actions, we found 
that there was a greater degree of deviation and supplementation of 
plans than stated by nursing home administrators.   
Additionally, when we evaluated the completeness of plans against a 
list of suggested provisions, we found that they were often lacking a 
number of the provisions.  For example, 6 of the 20 plans did not have 
instructions for evacuating to an alternative site, 9 plans did not have 
criteria or other guidance for making the decision to evacuate or 
shelter in place, 15 plans did not have information about the specific 
  OEI-06-06-00020  NURSING HOME EMERGENCY PREPAREDNESS AND RESPONSE DURING RECENT HURRICANES  ii  EE XX EE CC UU TT II VV EE    SS UU MM MM AA RR YY
needs of residents that would allow staff to modify plans according to 
residents needs, and 11 plans did not have instructions for reentry 
following evacuation. 
Lack of collaboration between State and local emergency entities 
and nursing homes impeded emergency planning and 
management. Local emergency managers often provided guidance 
regarding the decision to evacuate or shelter in place, and four of five 
Gulf States require local emergency managers to review nursing home 
emergency plans. Some communities were more involved with nursing 
homes than others, but generally, nursing homes managed evacuation 
or sheltering in place without guidance or evacuation assistance from 
State and local emergency entities. Evacuation assistance came 
primarily from parent corporations, sister facilities, and resident and 
staff family members. Administrators from five nursing homes that 
evacuated and one nursing home that sheltered in place reported that 
problems with State and local government coordination during recent 
hurricanes contributed to problems that they encountered. 
RECOMMENDATIONS 
To improve nursing home emergency preparedness and ensure effective 
execution of plans, we recommend the following: 
The Centers for Medicare & Medicaid Services (CMS) should 
consider strengthening Federal certification standards for nursing 
home emergency plans by including requirements for specific 
elements of emergency planning. CMS could develop a core set of 
required elements for inclusion in nursing home plans with corresponding 
changes to the Interpretive Guidelines for surveyors use in evaluating 
emergency plans. These required elements should apply to all Medicare 
or Medicaid-certified facilities, and also be tailored to address specific 
local risks. In developing this set of core elements, CMS could collaborate 
with State emergency management entities, nursing home associations, 
and other parties knowledgeable about nursing home operations or 
emergency preparedness. 
CMS should encourage communication and collaboration between 
State and local emergency entities and nursing homes. This effort 
could include providing guidance and technical assistance to States, 
facilitating a dialogue between nursing homes and emergency 
management authorities, and encouraging local emergency 
management review of facility emergency plans. 
OEI-06-06-00020  NURSING HOME EMERGENCY PREPAREDNESS AND RESPONSE DURING RECENT HURRICANES  iii  E X E C U T I V E   S U M M A R Y

AGENCY COMMENTS 
CMS concurred with both recommendations and outlined efforts 
underway to strengthen Federal certification standards and encourage 
collaboration between State and local emergency entities and nursing 
homes.  These efforts include reviewing regulatory requirements and 
interpretive guidelines for potential revision, implementing a 
communication strategy to disseminate information among States, CMS 
and health care facilities, and developing guidance for improved 
collaboration among Federal, State and local emergency entities. 
This evaluation was conducted in conjunction with the President's 
Council on Integrity and Efficiency (PCIE) as part of its examination of 
relief efforts provided by the Federal Government in the aftermath of 
Hurricanes Katrina and Rita.  As such, a copy of the report has been 
forwarded to the PCIE Homeland Security Working Group, which is 
coordinating Inspectors General reviews of this important subject. 
  OEI-06-06-00020  NURSING HOME EMERGENCY PREPAREDNESS AND RESPONSE DURING RECENT HURRICANES  iv    T A B L E   O F   C O N T E N T S  

EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i

I N T RO DUC T IO N  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1

F I N D IN G S  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  7

National and Gulf State EmergencyPreparedness. . . . . . . . . . . . .  7

Decision toEvacuate orShelter in Place. . . . . . . . . . . . . . . . . . . . .  8

Problems inEvacuating and Sheltering in Place. . . . . . . . . . . . . .  10

Evaluation of SelectedNursing Homes EmergencyPlans. . . . . .  16

Nursing Home Collaboration WithEmergencyEntities  . . . . . . .  18

R E C O MMEN D A T ION S  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  21

  AgencyComments  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  23

E N D NO T ES  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  25

APPENDIXES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  28

A:  Gulf State Requirements for Emergency Plans . . . . . . . . . . . .  28

B:  DetailedMethodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  29

C:  Suggested Provisions for Emergency Plans . . . . . . . . . . . . . . .  34

D:  Descriptions of Selected Hurricanes. . . . . . . . . . . . . . . . . . . . .  36

E:  AgencyComments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  38

A C K NO WL E D G M E N T S  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  41
   I N T R O D U C T I O N  

OBJECTIVES 
1.	 To determine the national and Gulf State incidence of nursing 

home deficiencies for lack of emergency preparedness. 

2.	 To examine the experiences of selected Gulf State nursing homes 
during recent hurricanes. 
3.	 To review the emergency preparedness plans of selected Gulf State 
nursing homes and evaluate nursing home use of plans. 
BACKGROUND 
Nursing home residents rely on nursing home staff to plan for and 
execute appropriate procedures to protect them during times of disaster.  
However, nursing home tragedies associated with recent hurricanes in 
the Gulf States have raised concerns about plans and coordination with 
State and local resources. In a congressional briefing, the Government 
Accountability Office indicated that [h]urricanes Katrina and Rita were 
incidents of national significance that highlighted the challenges 
involved in evacuating vulnerable populations, including those in 
hospitals and nursing homes.1  This study of facility emergency 
planning and execution responds to a request from Senator Herb Kohl, 
ranking member of the U.S. Senate Special Committee on Aging.2 
Federal Requirements for Nursing Home Emergency Preparedness 
Sections 1819 and 1919 of the Social Security Act establish 
requirements for nursing home participation in the Medicare and 
Medicaid programs.  The Secretary of the Department of Health and 
Human Services is responsible for ensuring that these requirements 
and their enforcement are adequate to protect the health, safety, 
welfare, and rights of residents and to promote the effective and 
efficient use of public moneys.3 Pursuant to Federal regulations, 
certified facilities are required to have detailed written plans and 
procedures to meet all potential emergencies and disasters, and must 
train employees in emergency procedures when they begin work in the 
facility, periodically review procedures, and carry out unannounced staff 
drills.4 
The State Operations Manual also requires that facilities consider, in 
the development of plans and training, geographic location and the 
types of residents served.5  Potential emergencies and disasters include 
a wide range of conditions, from a localized to a community-wide event. 
  OEI-06-06-00020  NURSING HOME EMERGENCY PREPAREDNESS AND RESPONSE DURING RECENT HURRICANES  1  I N T R O D U C T I O N  
Localized events impact only a single facility, whereas a  
community-wide event may impact all facilities within a specific 
geographical area.  Facilities may include in their written plans 
additional or more specific measures that are responsive to State and 
local authorities.6 
Verification of Nursing Home Compliance with Requirements 
The Omnibus Budget Reconciliation Act of 1987 established a survey 
and certification process for the Centers for Medicare & Medicaid 
Services (CMS) and States to verify that Federal standards are 
maintained in nursing homes certified for participation in the Medicare 
and Medicaid programs.  CMS has responsibility for enforcement of 
these standards, and contracts with State agencies to survey each 
facility to certify compliance with Federal standards.7 
Standard Surveys. State survey agencies are required to conduct 
standard surveys at least every 15 months or in abbreviated versions 
following complaints.8  The surveys include two measures of emergency 
preparation: having an emergency plan in place, and training staff in 
emergency procedures.9  To evaluate plans and training, CMS developed 
Interpretive Guidelines that instruct surveyors to ensure that the 
facility reviews its plan periodically and tailors it to the facilitys 
geographic location and to the types of residents it serves.10 
When State surveyors determine that the facility plan or training does 
not meet Federal requirements, they issue a deficiency tag that 
corresponds to specific regulations. The following are criteria stated in 
the surveyor guidelines for these tags: 
o	 F517The facility must have detailed written plans and 
procedures to meet all potential emergencies and disasters, such as 
fire, severe weather and missing residents,11 and 
o	 F518The facilities must train all employees in emergency 
procedures when they begin to work in the facility, periodically 
review the procedures with existing staff, and carry out 
unannounced staff drills using those procedures.12 
Life Safety Code Surveys. States also conduct Life Safety Code (LSC) 
surveys, often in conjunction with standard surveys.13  The LSC 
component is a compilation of fire safety requirements published by the 
National Fire Protection Association14 and incorporated into Medicare 
and Medicaid regulations.15  Although the LSC focuses on fire safety 
planning and conducting fire drills, its provisions are relevant to 
  OEI-06-06-00020  NURSING HOME EMERGENCY PREPAREDNESS AND RESPONSE DURING RECENT HURRICANES  2  I N T R O D U C T I O N  
evacuation during other emergencies (such as the use of prescribed 
methods for carrying fragile, nonambulatory residents to safety).  CMS 
Interpretive Guidance for LSC surveyors includes details regarding 
what the evacuation plan should include at a minimum, including 
questions for staff regarding the emergency plan, fire drill procedures, 
and details regarding fire drills.16  As with the standard surveys, to 
ensure adequate emergency preparedness, LSC surveyors issue 
deficiency tags when they determine that plans and training do not 
meet requirements.  The following are criteria stated in the surveyor 
guidelines for these tags: 
o K48There is a written plan for the protection of all patients and for 
their evacuation in the event of an emergency; and 
o	 K50Fire drills are held at unexpected times under varying 
conditions, at least quarterly on each shift.  Staff are familiar with 
procedures and aware that drills are an established routine.  
Responsibility for planning/conducting drills is assigned only to 
competent persons who are qualified to exercise leadership.17 
Additional Federal Oversight in Emergency Preparedness 
State and local authorities have primary responsibility for emergency 
management and the Federal Government plays a limited role. The 
Stafford Act specifies that the Federal Government assist State and 
local governments with their responsibilities during disasters by 
encouraging the development of comprehensive disaster preparedness 
and emergency assistance plans.18 
Each local jurisdiction is required to develop an Emergency Operations 
Plan (EOP) that defines the scope of preparedness under the guidelines 
of the National Incident Management System.19  Guidance for 
development of the EOP specifies that the plans evacuation directions 
include specific provisions for evacuating special needs individuals, 
including nursing home residents.20 
Additionally, Federal law requires that States establish a Long Term 
Care Ombudsman Program, funded by the Administration on Aging 
(AoA), to advocate for the care of residents in long term care facilities. 
The ombudsman program is responsible for monitoring policies that 
pertain to residents in long term care facilities.21  As a networking 
organization, AoA coordinates Government and nongovernment 
agencies, outreach programs, public issue forums, and disaster relief. 
AoA also directs efforts between Federal, State, and local authorities to 
meet the needs of the elderly population. 
  OEI-06-06-00020  NURSING HOME EMERGENCY PREPAREDNESS AND RESPONSE DURING RECENT HURRICANES  3  I N T R O D U C T I O N

Gulf State Requirements for Nursing Home Emergency Preparedness 
Four Gulf States (Florida, Louisiana, Mississippi, and Texas) impose 
additional requirements for nursing home emergency planning. 22 
Compliance with these additional provisions is verified by State 
licensing agencies in their periodic review of facilities to renew State 
licensure.  Florida and Texas have the most extensive additional 
requirements.  Louisiana developed a model plan to provide guidance to 
nursing homes for emergency planning.  Mississippi and Florida require 
facilities to use, as a minimum standard, criteria specified by Floridas 
Agency for Health Care Administration.23  (Appendix A provides a 
summary of all Gulf State requirements.). \
METHODOLOGY 
For this study, we (1) analyzed national and Gulf State survey data 
indicating noncompliance with Federal requirements for emergency 
plans and training; (2) collected information about the experiences of a 
selection of nursing homes affected by four hurricanes in 2004 or 2005 
(Ivan, Katrina, Rita, and Wilma), primarily through interviews with 
facility staff and community authorities; and (3) compared emergency 
plans from these selected nursing homes to a list of provisions compiled 
from informed sources. (See Appendix B for detailed methodology.) 
National and Gulf State Deficiencies 
We used CMSs Online Survey, Certification, and Reporting (OSCAR) 
data to determine the number of deficiencies nursing homes received for 
insufficient emergency plans and failure to adequately train staff for 
emergencies during calendar years 2004 and 2005 (nationally and 
specifically for Gulf States).  OSCAR maintains information on the four 
most recent standard surveys as well as complaint-generated surveys. 
Community and Nursing Home Selection 
The process of nursing home selection began with the review of 
localities.  Localities were chosen in a manner to ensure diversity in 
population size and proximity to a hurricane (see Box 1 on page 5 for 
hurricane details). Facilities within these localities were chosen in a 
manner to ensure diversity in size, ownership, and past State survey 
performance on emergency preparedness measures.24  We selected a 
total of 20 nursing homes that experienced 1 of the 4 hurricanes, and 
were located in 9 counties across 5 Gulf States (Alabama, Florida, 
Louisiana, Mississippi, and Texas) with 4 nursing homes selected per 
  OEI-06-06-00020  NURSING HOME EMERGENCY PREPAREDNESS AND RESPONSE DURING RECENT HURRICANES  4  I N T R O D U C T I O N  
State. Eleven nursing homes evacuated before the hurricane, two 
sheltered in place and then evacuated after the hurricane, and seven 
sheltered in place and never evacuated.  Selected localities included a 
large metropolitan area, several mid-size cities, and both suburban and 
rural communities.  
Box 1:  Selected Hurricanes 
All selected hurricanes were Category 3 at landfall, with winds of 111-130 
miles per hour and storm surges of 9-12 feet above normal. 
Alabama 
Mississippi 
Texas 
Louisi ana
Florida 
Hurricane Ivan 
Hurricane Rita  Hurricane Katrina 
Hurricane Wilma 
Ivan (September 2004):  25 deaths and estimated financial loss of $14 billion. 
Katrina (August 2005):  1,336 deaths and estimated financial loss of $75 billion. 
Rita (September 2005):  62 deaths and estimated financial loss of $10 billion. 
Wilma (October 2005): 5 deaths and estimated financial loss of $12 billion. 
Source:  National Weather Service National Hurricane Center Tropical Prediction Center. 
Data Collection  
We performed site visits to each of the selected nursing homes to 
conduct interviews with administrators and staff and to collect facility 
emergency plans and training records.  We also visited local government 
and aging services agencies in each nursing homes city and county. 
During each visit, we interviewed government authorities and local 
nursing home ombudsmen and collected community emergency plans. 
For each State, we conducted telephone interviews with officials from 
the emergency mangement office, nursing home licensing division 
(responsible for surveying facilities), nursing home associations, 
departments of aging services, and long term care ombudsmen. 
  OEI-06-06-00020  NURSING HOME EMERGENCY PREPAREDNESS AND RESPONSE DURING RECENT HURRICANES  5  I N T R O D U C T I O N  
Evaluation of Nursing Home Emergency PlansSuggested Provisions  
To assess the content of emergency plans from selected nursing homes, 
we compiled a list of emergency plan provisions, suggested by a number 
of informed sources, to compare to the actual plans.  A complete list of 
sources is provided in Appendix C and includes all Gulf State 
requirements and guidance, and a variety of published works from 
reputable sources such as the American Journal of Public Health.  
Additionally, we consulted with representatives from nursing home 
associations and emergency management agencies in all five Gulf 
States, and with other health care, elder care, and emergency 
preparedness experts.25  These informed sources were fairly consistent 
in identifying key provisions which they believe should be included in 
an effective emergency plan and represent basic tenets of emergency 
management.  We hereafter refer to this recommended list as 
suggested provisions. A complete list is provided in Appendix C.  We 
then reviewed the emergency plans of the 20 selected nursing homes to 
determine whether they included each of the suggested provisions. 
Data Limitations 
Although we diversified our selection of nursing homes, the purposive 
method used does not allow inference of results either to the Gulf States 
or the Nation. 
Quality Standards 
This study was conducted in accordance with the Quality Standards for 
Inspections issued by the Presidents Council on Integrity and 
Efficiency and the Executive Council on Integrity and Efficiency. 
  OEI-06-06-00020  NURSING HOME EMERGENCY PREPAREDNESS AND RESPONSE DURING RECENT HURRICANES  6    F I N D I N G S

Nationwide, 94 percent of nursing homes met  Of the 16,125 nursing homes 
Federal standards for emergency plans and 80  surveyed during 2004 and 2005, 
most met Federal standards, 
percent for sufficient emergency training in 2004-
with 6 percent cited for planning 
2005; compliance rates were similar for Gulf States 
deficiencies and 20 percent cited 
for training deficiencies (see Table 1).26  A greater proportion of the 
deficiencies issued for both inadequate emergency planning and 
training were from LSC surveys rather than standard surveys.  The 
greater frequency of citations from LSC surveys may be a result of LSC 
surveyors focusing more directly on facility safety provisions, while 
standard surveyors cover a much broader range of issues addressing 
multiple aspects of nursing home resident health and well being.27 
Table 1.  Nursing Homes Cited with Deficiencies for Emergency Planning and Training:   
National and Gulf States (2004-2005) 
NATIONAL 
2004  2005  Total** 
Facilities  %  Facilities  %  Facilities  % 
(n = 15,135)  (n = 15,011)  (n = 16,125) 
Planning Deficiencies 
Standard Survey F517  168  1.1  161  1.1  307  1.9 
Life Safety Code K48  262  1.7  420  2.8  655  4.1 
Total Facilities with Planning Deficiencies*  425  2.8  565  3.8  929  5.8 
Training Deficiencies 
Standard Survey F518  467  3.1  438  2.9  851  5.3 
Life Safety Code K50  1,326  8.8  1,624  10.8  2,695  16.7 
Total Facilities with Training Deficiencies*  1,685  11.1  1,954  13.0  3,265  20.3 
GULF STATES 
2004  2005  Total 
Facilities   %  Facilities  %  Facilities  % 
(n = 2,375)  (n = 2,379)  (n = 2,526) 
Planning Deficiencies 
Standard Survey F517  13  < 1  7  < 1  20  < 1 
Life Safety Code K48  62  2.6  80  3.3  135  5.3 
Total Facilities with Planning Deficiencies*  75  3.2  87  3.7  155  6.1 
Training Deficiencies 
Standard Survey F518  92  3.9  106  4.5  193  7.6 
Life Safety Code K50  194  8.2  211  8.9  381  15.1 
Total Facilities with Training Deficiencies  276  11.6  301  12.7  535  21.2 
*The total planning and training deficiencies is not the sum of the standard survey and LSC deficiencies because some facilities had one of each type, 
resulting in some overlap in the categories. 
**Totals do not equal the sum of 2004 and 2005 because some nursing homes were cited in both years. 
Source:  Office of Inspector General analysis of OSCAR data for CYs 2004-2005. 
  OEI-06-06-00020  NURSING HOME EMERGENCY PREPAREDNESS AND RESPONSE DURING RECENT HURRICANES  7  FF II NN DD II NN GG SS  
The proportion of nursing homes with emergency preparedness 
deficiencies in Gulf States was similar to the national level. Six percent 
of the 2,526 facilities surveyed in Gulf States during 2004 and 2005 
were cited with deficiencies for not having adequate emergency plans in 
place, and 21 percent were cited for insufficient staff training. As at the 
national level, LSC surveyors issued the majority of deficiencies 
regarding emergency preparedness in the Gulf States. All of the 
20 nursing homes we selected for onsite evaluation were determined by 
State surveyors to have adequate emergency plans in place in their 
most recent 2005 State survey. However, 3 of the 20 selected nursing 
homes were cited for not sufficiently training staff.28 
The current Federal survey standards and guidance to surveyors do not 
specify the content that emergency training should include. Nor do they 
require surveyors to ensure that emergency plans include specific 
instructions for evacuating and sheltering in place. Based on interviews 
with surveyors in Gulf States and documentation of actual deficiencies 
cited, nursing homes are commonly cited for inadequate emergency 
plans for the following reasons. 29 The plan: 
o	 does not account for all types of emergencies, e.g., hurricanes, fires; 
o	 does not include provisions for the care of residents, e.g., 
instructions for special needs residents; and/or 
o	 is not reviewed by staff and updated annually. 
Additionally, nursing homes were cited for training deficiencies when 
staff were unable to demonstrate knowledge of procedures to surveyors, 
or when they were unable to produce records demonstrating that they 
provided training to all staff at the frequency required. 
Of the 20 nursing homes we 
Multiple factors, including community evacuation 
selected for onsite evaluation, 
orders, influenced the decision of selected 
11 evacuated before the hurricane, 
nursing homes to evacuate or shelter in place 
2 sheltered in place then 
evacuated after the hurricane, and 7 sheltered in place and never 
evacuated. All nursing home administrators reported that an 
evacuation can cause physical and mental stress on nursing home 
residents, and consequently is not necessarily the best course of action 
for residents during hurricanes. Administrators also reported that 
sometimes sheltering in place is the safer (and also less expensive) 
alternative, particularly in the case of hurricanes during which storms 
OEI-06-06-00020  NURSING HOME EMERGENCY PREPAREDNESS AND RESPONSE DURING RECENT HURRICANES  8  F I N D I N G
 S  
can quickly shift and reduce risk to residents and staff.  Administrators 
reported that they consider a wide range of factors in making the 
decision whether to evacuate or shelter in place, such as the storms 
characteristics, the facility structure and location, the availability of 
resources, and the health status of residents. 
Deciding to evacuate. For 9 of the 11 nursing homes that evacuated 
before the hurricane, administrators reported that they collaborated 
with facility owners in making the decision to evacuate.  In the other 
two cases, emergency management authorities mandated evacuation.30 
In addition to these two mandatory evacuation orders, four facilities 
evacuated even though the evacuation order was voluntary or there 
was no order at all. We found differing interpretations of what 
mandatory or voluntary evacuation orders mean among both 
administrators and government authorities.  But in most cases, 
facilities reported that a voluntary order was a suggestion to evacuate 
or served as a precursor to a mandatory order, and that a mandatory 
order meant the facility must evacuate or risk losing access to 
emergency services.  Nursing home administrators often reported that 
they did not consider an evacuation order a clear mandate.   
In the case of the two nursing homes that evacuated after initially 
sheltering in place, their decision to evacuate was based on 
circumstances after the storm passed.  Administrators from these 
facilities reported that they were uncertain about their electricity and 
water supply, and were concerned with resident and staff safety in light 
of reduced police capability.   
Deciding to shelter in place.  Although the factors guiding decisions to 
shelter in place were similar to those for evacuation, circumstances 
caused these administrators and owners to determine that the risks 
were greater in evacuating than in sheltering in place.  Administrators 
at these nursing homes reported the following:  facility structure was 
sound enough to withstand expected high winds, location limited the 
degree of expected flooding, staff were proficient in emergency response 
and willing to shelter in place with residents, the community was likely 
to augment facility resources, and the poor condition of residents made 
travel dangerous, e.g., one facility had a large number of hospice 
patients. Additionally, some of these administrators reported that they 
were determined to avoid evacuating if possible due to negative past 
experiences with evacuation.  Administrators from two of the nine 
nursing homes that sheltered in place reported that they did not 
  OEI-06-06-00020  NURSING HOME EMERGENCY PREPAREDNESS AND RESPONSE DURING RECENT HURRICANES  9  FFF III NNN DDD III NNN GGG SSS  
evacuate in part because they were unable to locate enough space in 
other nursing homes to accommodate all residents. 
Administrators and staff in selected 
All 20 of the selected Gulf State nursing homes 
nursing homes reported a range of 
experienced problems, whether they evacuated 
experiences, but similar problems 
or sheltered in place 
emerged across States, 
communities, and facilities. In some cases, reported problems could be 
tied to a lack of planning or failure to execute emergency plans. In 
others, the circumstances of the hurricane and its effect on resources 
and community services were such that prior planning may not have 
anticipated the specific problems encountered, and impromptu decisions 
and actions were required. 
All 13 nursing homes that evacuated encountered problems in the process 
of leaving and returning to their facilities 
Administrators of nursing homes that evacuated reported problems at 
each stage of the evacuation process, the most prominent including: 
o transportation contracts were not always honored, 
o evacuation travel took longer than expected, 
o medication needs complicated travel, 
o host facilities were unavailable or inadequately prepared, 
o facilities could not maintain adequate staff, 
o food and water shortages occurred or were narrowly averted, and 
o prompt return of residents to facilities was difficult. 
Transportation contracts were not always honored. All 13 nursing homes 
that evacuated reported they had prior contracts for transportation 
(10 facilities provided documentation), but services were not available 
for 5 of these because the vehicles were in use by other parties in the 
hurricanes path. This reportedly happened in part because multiple 
nursing homes contracted with the same companies, typically the 
company used for routine ambulance services. These nursing homes 
often discovered the problem only days or hours prior to the evacuation, 
and were forced to find alternate transportation. Administrators from 
two nursing homes resorted to the telephone directory to locate 
transportation resources. Others were able to use connections with 
other nursing homes and within the community to secure assistance 
from sources, including churches, school districts, and taxicab 
companies. 
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Evacuation travel took lonoer than expected. Four of the thirteen evacuated
nursing homes had problems during the trips from their facilities to
host facilities, and three of these were forced to move residents more
than once. The median trip time to a host facility was 3 hours, but in
the case of one facility evacuating from Houston prior to Hurricane Rita,
the trip to the host facility took as long as 19 hours (see Box 2 for a
description ofthe experience). Problems occurred primarily when trips
took longer than anticipated, and either the weather, traffc, inadequate
vehicles, or limits in supplies made residents and staff uncomfortable.
Box 2: The Experience of One Selected Nursing Home In Transit
The nursing home administrator and other staff reported that the facility emergency plan had minimal instructions
for evacuation. For example, there was instruction regarding packing food, but no guidance regarding water or
medication. The contracted transportation was unavailable and fewer than a quarter of staff remained to
evacuate with residents. A mix of staff and borrowed vehicles was cobbled together in the final hours before the
hurricane made landfall, and a nine-vehicle convoy began what normally would be a 2-hour trip to a campground.
The convoy was part of a widespread evacuation of a large metropolitan area. Traffc on all outbound highways
was slow. Staff reported that temperatures reached 104 degrees and water among residents and staff quickly
reached ration leveL. Other supplies were also inadequate. For example, one resident vomited early in the trip
and staff had no cleaning materials. The drivers could not attempt an alternative route because none had maps.
After 4 hours, one of the vans broke down and residents were unloaded and crowded into other vehicles. The
next morning, after 12 hours on the road, another van broke down and residents were loaded into the remaining
vehicles. Oxygen became low, and after callng the nearest town from a cell phone, the local emergency
management service delivered an inadequate number of cylinders. Temperatures by midday again climbed over
100 degrees and the air conditioners in the two resident vans were inoperable.
Once the convoy got close to the camp, camp managers sent two replacement vans and residents were
redistributed again; however, only one of the camp vans had air conditioning. All vehicles had been out of water
for hours and staff were able to change incontinence supplies only once. Other than one resident who was given
a nurse's personal insulin, none of the residents received medication. Residents arrived at the camp after
19 hours in transit. All residents survived, but several were treated for cuts and bedsores resulting from the trip.
Source: Summary of evacuation description reported by the facility administrator.
Medication needs complicated travel. Three of the thirteen evacuated
facilities had problems with medication. Administrators reported this
occurred because trips took longer than expected, medications were not
readily available during transit, or medications were improperly packed
and supervised. For example, during one evacuation staff had
medication on the vehicles but had not packed the equipment needed to
administer the medication. In another case, a resident became
disruptive and required sedation, but his medication was located on a
different vehicle. Staff from another selected nursing home kept
medications in small plastic bags with individual residents, and had to
prevent residents from inappropriately exchanging medications.
OEI.06.06.00020 NURSING HOME EMERGENCY PREPAREDNESS AND RESPONSE DURING RECENT HURRICANES 11 F I N D I N G
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Host facilities were unavailable or inadequately prepared.  Twelve of the 
thirteen selected nursing homes that evacuated reported they had 
formal agreements with host facilities to temporarily house residents in 
the case of an evacuation (eight facilities provided documentation).  The 
remaining nursing home had an informal, verbal agreement. 
Contracted host facilities were available when needed for 11 of the  
13 selected nursing homes that evacuated.  In the two cases where 
facilities were not available, the facilities either evacuated themselves 
or had already reached capacity with residents from other contracted 
nursing homes.  These administrators sought alternatives, as they did 
for transportation, through connections with other nursing homes and 
community entities.  In three Gulf States, nursing home associations 
and State human services offices actively sought facilities that could 
provide beds for nursing home residents throughout their States.  
Seven of the selected nursing homes had agreements with multiple host 
facilities, meaning that residents were evacuated to different host sites 
depending on their needs and the availability of beds.  For five of the 
seven facilities, these agreements were with nursing homes under the 
same ownership or within the same nonprofit network, but the other 
two facilities had agreements with alternative sources, such as schools, 
churches, and camps.31  When nursing homes had sister facilities, they 
often shared other aspects of emergency management, such as 
transportation, staff, and supplies.  
Placing residents in alternative shelters not designed for the care of 
elderly and disabled posed particular challenges.  When evacuated to 
other nursing facilities or hospitals, residents were integrated into the 
existing care routine and usually had access to necessary supplies, staff, 
and equipment, but when evacuated to schools, churches, or camps, 
staff had to create the proper environment.  One nursing home had an 
agreement to shelter at a school and placed residents in a gymnasium 
on air mattresses that needed to be continually reinflated.  At the same 
time, the generator failed at the school and water was shut off for  
24 hours due to the storm.  Because of these problems, residents 
returned to their facility and evacuated 3 days later to a host nursing 
home. 
Even when placed in an adequate host facility, problems with resident 
care sometimes occurred.  Administrators of three nursing homes that 
evacuated to other nursing homes or hospitals reported problems with 
supplies and inadequate staffing. One host nursing home lacked both 
  OEI-06-06-00020  NURSING HOME EMERGENCY PREPAREDNESS AND RESPONSE DURING RECENT HURRICANES  12  F I N D I N G S  
beds and supplies to accommodate residents, and did not have locks 
needed to protect residents with Alzheimers disease from wandering.  A 
nursing home that evacuated to an unused portion of a full-service 
hospital encountered outdated facility structures and unusable medical 
equipment and supplies.   
Facilities could not maintain adequate staff. Six of the thirteen nursing 
homes reported that they had staffing shortages during the evacuation, 
both at the host facility and when returning to the facility.  In some 
cases, facilities had a fairly large number of staff but lacked staff with 
necessary qualifications.  For example, one facility reported there were 
not enough registered nurses when they reached the host facility.  In 
this case, the available nurses worked overtime but reported they were 
ultimately unable to fully cover all resident needs.  Two selected 
nursing home administrators reported that some staff refused to assist 
with facility evacuation, but most administrators reported staff were 
available and dedicated to meeting the needs of facilities and residents.  
All evacuating nursing homes allowed staff to bring families along for 
the evacuation; a decision that administrators reported was critical to 
retaining staff during the evacuation.   
Food and water shortages occurred or were narrowly averted. Two of the 
thirteen selected nursing homes reported shortages of food and water.  
This occurred even though the emergency plan for one of the facilities 
specified the amount of food needed.  Other administrators reported 
many other potential shortages were averted by utilizing sources not in 
their emergency plans, such as local churches, and that these 
supplements often came a short time before supplies would have run 
out.  As with staffing problems, food and water supply problems 
appeared to be caused at least in part by a lack of prior planning.  For 
8 of the 13 nursing homes that evacuated (including both of the facilities 
with shortages), the facility emergency plan specified the amount of food 
and water they should have if they sheltered in place, but did not 
specify the amounts that should be taken when evacuating.  The 
emergency plans for 2 evacuated nursing homes did not address the 
provision of water during evacuation, and the plans for 10 did not 
address the amount or type of food to be packed. 
Prompt return of residents to facilities was difficult.  Ten of the thirteen 
nursing homes reported problems returning to their facilities after 
absences ranging in duration from 24 hours to several months.  
Difficulties ranged from scheduling staff to prepare the facility for 
  OEI-06-06-00020  NURSING HOME EMERGENCY PREPAREDNESS AND RESPONSE DURING RECENT HURRICANES  13   
   
F I N D I N G S  
residents return to arranging transportation for residents who were 
provided housing out-of-State.  Five of the thirteen facilities sustained 
damage from the hurricanes; three suffered relatively minor damage, 
such as broken windows and partial flooding, but the remaining two, 
both in Mississippi, were completely destroyed (see Figure 1 on  
page 14).32  Even when nursing homes did not suffer actual damage, 
administrators reported that their facilities often needed substantial 
cleaning and restocking before residents could return.  Following 
hurricane Katrina, Louisiana required inspections by State licensing 
surveyors before residents could return. 
Seven of the thirteen nursing homes reported problems with staffing 
upon reentry, either because staff were delayed or were unable to return 
to work due to the widespread disaster.  In communities that were hit 
by Katrina, some staff were unable to assist because of the extreme 
difficulty in traveling and the extent of devastation to their own 
property.  In these communities, city managers and other local leaders 
reported that there is still a lack of housing for low-income staff.  
Several staff from selected Louisiana and Mississippi nursing homes 
lost their homes and all belongings in the storm.  To help 
administrators operate during the transition, one facilitys owners sent 
staff from other facilities to fill in until new staff could be hired.   
  Figure 1.  Photo of Destroyed Selected Nursing Home in Mississippi 
  Source:  Office of Inspector General Photo 2006. 
 
 
 
  OEI-06-06-00020  NURSING HOME EMERGENCY PREPAREDNESS AND RESPONSE DURING RECENT HURRICANES  14  F I N D I N G
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Administrators from 5 of the 13 nursing homes that evacuated reported a 
negative impact on resident health 
Negative health effects were typically isolated to a small portion of 
residents and could not usually be linked to particular facility problems 
during evacuation.  Of the administrators that reported a negative 
impact on resident health in their nursing homes, four reported that 
residents had physical problems and three reported that the evacuation 
was psychologically difficult, with some residents showing signs of 
depression (one facility reported both of these problems).  Some of this 
negative impact was short term, as in the case of one nursing home 
where a lack of necessary provisions during evacuation, such as water, 
bandages, and incontinence supplies, caused residents to be 
uncomfortable and even temporarily dehydrated.  In other cases, the 
impact was long term, such as a resident who was hospitalized due to a 
fall at the host facility caused by his unfamiliarity with his new 
environment, and residents who were reported to have developed skin 
tears and pressure sores during transport.   
Nursing homes that sheltered in place encountered fewer problems, but 
they were severe enough that two of the nine facilities later evacuated  
Facilities that sheltered in place most often reported problems with 
staffing and uncertainty over their access to community resources. In 
two cases, these problems caused the facilities to evacuate after the 
storm.  Two nursing homes that sheltered in place and did not later 
evacuate also reported difficulties with staffing, yet neither of these 
problems appeared to be substantial.  In both cases, administrators 
called in additional staff from their own roster or a sister facility to 
cover for staff that were leaving the area.  None of the nine facilities 
that sheltered in place reported problems with supplies, but just as with 
the evacuated facilities, some shortages were narrowly averted.  
Facilities that sheltered in place received supplies such as food and 
water through donations from local authorities or service organizations.   
Power was disrupted for five of the nine facilities that sheltered in 
place, with reported outages ranging from 2 hours to as long as 4 weeks. 
All of these facilities had generators that worked when they were 
needed.  Some administrators reported that they plan to purchase 
larger generators for future storms because they found that providing 
air conditioning in high temperatures taxed their generators to the 
maximum or did not allow for more than lighting and fans.  An 
administrator from one of the nine facilities that sheltered in place 
reported a negative impact on resident healtha tree fell into the 
  OEI-06-06-00020  NURSING HOME EMERGENCY PREPAREDNESS AND RESPONSE DURING RECENT HURRICANES  15  F I N D I N G S  
facility. While this was reported to be traumatic for residents, it did not 
cause any injuries. However, as with other nursing homes in Florida, 
this administrator reported that luckily temperatures were fairly cool 
and residents were able to stay comfortable without air conditioning. 
All emergency plans from the   
Administrators and staff from selected nursing 
20 selected nursing homes met 
homes did not always follow emergency plans 
Federal requirements on their most 
and plans often lacked suggested provisions 
recent State survey.  However, we 
found that procedures followed by administrators and staff during the 
recent hurricanes were often inconsistent with these emergency plans.  
Also, the emergency plans were often missing a number of the 25 plan 
provisions suggested by our informed sources. 
Administrators perceived their emergency plans as sufficient, but the 
procedures followed were often inconsistent with their plans 
Administrators from all 20 selected nursing homes reported that they 
believed their facility emergency plans were sufficient for managing an 
emergency response.  Additionally, our discussions regarding specific 
plan provisions suggested that administrators were often not fully 
aware of the contents of their emergency plans.  For example, 
administrators of 9 of the 20 selected nursing homes indicated that their 
plans included ensuring adequate food, water, and medication when, in 
fact, none of these provisions were in their plans.   
Administrators from 5 of the 20 selected nursing homes reported that 
they deviated from or worked beyond their emergency plans during the 
recent hurricanes, either because the plans were not updated with 
current information or did not include instructions for particular 
circumstances.  Administrators from the remaining 15 nursing homes 
reported that they largely followed their emergency plans.  However, 
when comparing details of their plans to their reported actions, we 
found that there was a greater degree of deviation and additions to 
plans than stated by administrators.  For example, staff at one nursing 
home deviated from its transportation plan by evacuating to an 
uncontracted host facility closer than the contracted host to reduce 
resident travel time.  In another case, nursing home staff added 
substantially to its emergency plan. That plan included only a very 
general description of evacuation procedures, but when faced with 
evacuation they created a lengthy impromptu plan which included 
  OEI-06-06-00020  NURSING HOME EMERGENCY PREPAREDNESS AND RESPONSE DURING RECENT HURRICANES  16  F I N D I N G
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detailed checklists for staff to use in packing supplies and transporting 
residents. 
Further, nursing home administrators from our selected nursing homes 
did not always rely on plans as practical manuals for disaster 
management.  In most cases, nursing home administrators reported 
that they and their staff improvised actions based on prior experience or 
their knowledge of the tasks required to meet residents needs and 
ensure their safety.  It is important to recognize, however, that facilities 
cannot guarantee that experienced staff members will be available and 
able to orchestrate a facilitys response to a disaster. 
Nursing home emergency plans were often missing a number of the  
25 suggested plan provisions 
Although these provisions are not required by CMS or all Gulf States, 
informed sources, such as State licensing agencies, nursing home 
associations, emergency managers, and elder care experts, maintain 
that these provisions strengthen preparedness.  Although 15 of the  
20 selected emergency plans included a majority of the 25 suggested 
plan provisions, the following are examples of suggested provisions that 
were missing (see Appendix C for a complete list of the provisions we 
used in this review and the number of emergency plans that had each):  
o	 nine plans did not include criteria or other guidance for making the 
decision to evacuate or shelter in place; 
o	 fifteen plans did not have information about the specific needs of 
residents that would allow staff to modify emergency plans 
according to residents needs, such as special equipment (oxygen, 
feeding tubes), a measure of the level of residents mobility, mental 
status, and bowel/bladder control, and other factors pertinent to 
transportation, security and care needs, e.g., Alzheimers patients 
require locked units or alarms on doors; 
o	 six plans did not include instructions for evacuation to an 
alternative site, such as transportation routes and care of residents 
in transit; 
o	 six plans did not include a formal agreement for a host facility to 
house residents in the event of evacuation;  
o seven plans did not include staff responsibilities for evacuating, 
such as descriptions of which staff are expected to evacuate with 
residents and under what circumstances; 
  OEI-06-06-00020  NURSING HOME EMERGENCY PREPAREDNESS AND RESPONSE DURING RECENT HURRICANES  17  F I N D I N G S  
o	 thirteen plans did not include provision for water needed during 
evacuation and six did not include provision for food, either the 
amount needed or details about transporting the supplies; and 
o	 eleven plans did not include instructions for reentry following 
evacuation, such as determining who will inspect the facility to 
approve reentry, instructions for cleaning and repairs, plans for 
scheduling staff, and transportation for residents to return. 
Nursing home administrators, 
Lack of collaboration between State and local 
local emergency management 
emergency entities and nursing homes impeded 
authorities, and other 
emergency planning and management   
community entities reported 
that limited collaboration in preparing for and managing nursing home 
emergency preparedness and response to hurricanes sometimes 
impeded nursing home access to resources and information. 
When State and local authorities provided assistance to nursing homes, 
it was typically to review their emergency plans.  Four of five Gulf 
States require nursing homes to submit plans to State or local 
emergency management agencies for review (Florida, Louisiana, 
Mississippi, and Texas).  We found that these reviews vary in their 
rigor, but provide an additional layer of oversight by authorities 
knowledgeable about the specific needs of the area and its residents.  
Through the review process, emergency managers were often given the 
opportunity to make recommendations and follow up on resulting 
changes to the plans.  For example, in Florida, emergency managers 
review nursing home plans to ensure that they meet State guidelines 
if the reviewing emergency manager reports that plans do not meet 
these requirements, the facility can be found deficient by State 
surveyors. In some cases, reviews appeared to serve an ancillary 
purpose of helping to develop a line of communication between 
emergency management staff and nursing homes.  
Limited collaboration caused communities and nursing homes to miss 
opportunities for better emergency management and restricted nursing 
home access to resources   
Administrators from 5 of the 13 evacuated facilities reported that 
problems with government coordination during these hurricanes 
contributed to or exacerbated problems they encountered.  For example, 
some local emergency staff did not return calls from nursing homes 
seeking assistance.  Administrators, community leaders, and emergency 
managers largely reported that communities accept little responsibility 
  OEI-06-06-00020  NURSING HOME EMERGENCY PREPAREDNESS AND RESPONSE DURING RECENT HURRICANES  18  F I N D I N G
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for nursing homes during disasters. Some communities were more 
involved with nursing homes than others, but in general, nursing homes 
managed evacuation or sheltering in place without assistance from 
community authorities. Assistance came from parent corporations, 
sister facilities, or resident and staff family members. 
Additionally, nursing homes are often not included in community 
emergency planning.  In some cases, this lack of collaboration appears 
to be caused in part by the fact that nursing homes are categorized by 
community authorities as businesses rather than as health care 
institutions.  For example, in one community, the city and county 
organized a task force to explore the needs of vulnerable citizens during 
disasters.  The task force included representation from hospitals and 
ambulatory care centers, but not from nursing homes. In a smaller 
community in another State, the county emergency management plan 
includes provisions for hospitals but does not address nursing homes.   
Nursing home administrators reported that they view transportation as 
the most pressing need for community collaboration during disasters.  
Of special concern is regulating transportation contractors who promise 
resources to many facilities, and making city and county transportation 
sources available to residents if needed.  Local leaders and advocates 
frequently mentioned a desire to establish a more comprehensive 
community transportation plan, including building transportation 
networks, possibly even across States, and to consider engaging 
alternative transportation such as unused rail lines. Local authorities 
in all selected communities reported that they would be willing to 
participate in coordinating and providing transportation. 
Another cause of difficulty is that community resources in place for 
other citizens might not be available to nursing home residents.  
According to local officials, four of the five Gulf States (Florida, 
Mississippi, Louisiana, and Texas) discourage or restrict nursing homes 
from using State special needs shelters as evacuation sites for their 
residents, reserving the shelters for homebound residents.33  Nursing 
home residents in Alabama are permitted to evacuate to special needs 
shelters at the discretion of facility administrators.  Community 
authorities also reported that transportation resources may be 
restricted for nursing home residents.  In these cases, emergency 
managers assume that nursing home owners have planned for 
evacuation transportation, and community-based transportation sources 
are focused on the elderly and others living independently. 
  OEI-06-06-00020  NURSING HOME EMERGENCY PREPAREDNESS AND RESPONSE DURING RECENT HURRICANES  19  N 0 N G S
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The collaboration between community authorities and nursing homes in
the same State sometimes differed substantially even though they were
faced with similar storm conditions and resource limitations. The
ilustration in Box 3 on page 20 contrasts the experiences of nursing
homes in two contiguous counties, one with substantial collaboration
between the community and nursing homes both prior to and during the
storm and the other with little collaboration or direct services.
Box 3. An Example of the Integration of Nursing Home and Community Emergency Planning
The first, more rural county had emergency management staff that works closely with nursing home
administrators and have ongoing informal communication. In addition to reviewing plans, they advise
nursing homes about improving plans and integrating with community plans as they evolve. Emergency
managers knew the specific risk factors for each nursing home and were able to advise whether to
evacuate, to designate special shelters, and to provide emergency generators. Prior to the storm,
emergency managers in this county made contact with nursing homes to ensure that planned resources
were in place and assisted the nursing homes with the evacuation and reentry processes.
In the other, more urban county, emergency managers and nursing homes have more formal
relationships. They review nursing home emergency plans, but rely on the State to give nursing homes
feedback regarding the adequacy of the plans. One nursing home administrator reported that "we are
supposed to send our plan to the (agency), but we are not sure what they do with it." When the hurricane
struck, this facility decided to shelter in place. They weathered the hurricane and flooding well, but during
the aftermath, the lack of community support became apparent. This facility subsequently evacuated for
security reasons and also helped with the evacuation of another facility in the same county that was
unable to get help from the emergency management agency.
Source: Summary of interviews with various community and nursing home respondents.
State long term care ombudsmen rarely have a direct role in working with
area nursing homes in emergency planning
All five Gulf States have long term care ombudsmen programs that
serve as advocates for nursing home residents. These programs provide
indirect assistance during disasters through their routine practice of
monitoring occupancy of nursing homes and tracking resident locations.
However, ombudsmen programs in four of the five Gulf States do not
specifically work with nursing homes on emergency planning or disaster
management. In Texas, the one State where the program does perform
this role, local ombudsmen review nursing home emergency plans, offer
technical assistance, and provide training to nursing home staff on
quality of life issues and emergency procedures. In interviews, local
ombudsmen from all five States expressed interest in joining community
efforts to work with nursing homes regarding emergency management.
OEI.06.06.00020 NURSING HOME EMERGENCY PREPAREDNESS AND RESPONSE DURING RECENT HURRICANES 20   R E C O M M E N D A T I O N S  

State surveyors determined that, as of their most recent survey, each of 
the 20 selected Gulf State nursing homes complied with Federal 
standards for emergency planning.  However, in comparing these plans 
to a list of suggested emergency plan provisions that we compiled from 
the informed sources, we found that few plans included all provisions.  
While these provisions are not required by CMS or Gulf States, 
numerous informed sources agree that these provisions are critical to an 
effective emergency plan and, left unaddressed, could jeopardize a 
nursing homes response in the face of a disaster.   
Further, we found that nursing home administrators did not always 
understand or adhere to emergency plans during their hurricane 
evacuations.  This finding, along with problems identified by these 
nursing homes during evacuation or sheltering in place, indicate that 
challenges exist in nursing home emergency planning and plan 
execution. These challenges center primarily on two areas:  (1) nursing 
home emergency plans do not include all elements needed to guide staff 
decisions and actions during disasters, and (2) nursing homes are often 
not actively involved in the community-wide planning and coordination 
efforts critical to executing an effective disaster response.  
To improve nursing home emergency preparedness and ensure effective 
execution of plans, we recommend the following: 
CMS should consider strengthening Federal certification standards for 
nursing home emergency plans by including requirements for specific 
elements of emergency planning 
While some Gulf States are making efforts to improve their emergency 
planning, not all of them currently require nursing home plans to include 
provisions considered critical to an effective emergency plan, according to 
State licensing agencies, nursing home associations, emergency managers, 
and elder care experts. In addition, current Federal standards for 
emergency plans provide only general guidance. Thus, to strengthen 
emergency planning and to better protect nursing home residents, CMS 
could develop a core set of required elements for inclusion in nursing home 
plans with corresponding changes to the Interpretive Guidelines for 
surveyors use in evaluating emergency plans.  These required elements 
could apply to all Medicare or Medicaid certified facilities and be tailored 
to address specific local risks or could apply to only those facilities in 
States considered by CMS most at-risk for wide area disasters, such as the 
hurricanes that recently struck the Gulf States. 
  OEI-06-06-00020  NURSING HOME EMERGENCY PREPAREDNESS AND RESPONSE DURING RECENT HURRICANES  21  R E C O M M E N D A T I O N S  

Based on the experiences of our selected nursing homes, we suggest that, 
at a minimum, CMS should consider adding core elements to address the 
following areas.  These elements would supplement the broad Federal 
requirement that nursing homes develop detailed written emergency plans 
and procedures: 
o	 Plan for evacuation, including actionable details on travel; provision 
of supplies; transport of records, medications and belongings; 
agreement for host facility; and reentry to facility after evacuation. 
o	 Plan for sheltering in place, including a backup source of electricity 
and sufficient supplies of food, water, and medications. 
o	 Plan for addressing specific needs of residents, including needs of 
residents in hospice care, and of those with Alzheimers disease, 
bowel/bladder problems, and limited mobility.  
o	 Plan for adequate staffing levels, including clear expectations for 
relocation, if necessary, and for assistance with residents in an 
emergency; as well as including provisions for staffs family 
members. 
o	 Plan for collaboration with emergency managers and other 
community entities to better assure success of emergency plans. 
In developing this set of core elements, CMS could collaborate with State 
emergency management entities, nursing home associations, and other 
parties knowledgeable about nursing home operations or emergency 
preparedness. To assist nursing homes in incorporating the required 
elements into their plans, CMS could also create a guide for facility 
emergency preparedness that provides examples of plan language and 
considerations for evacuation and sheltering in place, such as CMSs 
manual of emergency preparedness for dialysis facilities issued in 2003.34 
CMS should encourage communication and collaboration between State and 
local emergency entities and nursing homes 
To ensure that nursing homes protect residents with effective, 
community-specific responses to future disasters, CMS should 
encourage States to enhance community involvement in nursing home 
emergency planning and plan execution. We recognize that CMS is not 
responsible for community coordination of emergency efforts, but we feel 
that CMSs influence would be beneficial in assisting homes with this 
effort.  CMS action could include providing guidance and technical 
assistance to States to open a dialogue between nursing home 
stakeholders and emergency management authorities, encouraging local 
  OEI-06-06-00020  NURSING HOME EMERGENCY PREPAREDNESS AND RESPONSE DURING RECENT HURRICANES  22  R E C O M M E N D A T I O N S  
emergency managers to review facility plans, and finding opportunities 
to raise the awareness of nursing homes needs within the community 
and among government authorities involved in emergency management. 
This assistance to States should target issues of importance to both 
facilities and communities, such as transportation and distribution of 
resources during emergencies.  In implementing this recommendation, 
CMS should consider engaging other relevant staff and resources in the 
Department, such as AoAs State Long Term Care Ombudsman 
Program and the Office of Public Health Emergency Preparedness.  
AGENCY COMMENTS 
CMS concurred with both recommendations and outlined efforts 
underway to implement them.  In response to our recommendation that 
CMS consider strengthening Federal certification standards for nursing 
home emergency plans, CMS indicated that it was currently reviewing 
regulatory requirements and interpretive guidelines to determine how 
they can be strengthened and the most appropriate methods of 
improving the preparedness standards applicable to health care 
facilities. CMS also commented that it is in regular communication 
with States, accrediting organizations, and other stakeholders to 
determine effective approaches to improve preparedness, ensure the 
presence of contingency plans, promote coordination with State and 
local entities, and improve staff training in emergency preparedness. 
In response to our recommendation that CMS should encourage 
communication and collaboration between State and local emergency 
entities and nursing homes, CMS reported that it plans to implement a 
communication strategy that will disseminate information among State 
survey agencies, CMS regional offices, and health care facilities. 
Additionally, CMS reported participation in several departmental and 
interagency workgroups that are developing recommendations and 
guidance for improved collaboration and coordination among Federal, 
State, and local emergency entities.  For example, one workgroup is 
reviewing, assessing, and developing national definitions, 
recommendations, and targets to address emergency planning, hazard 
mitigation, and response and recovery for all aspects of health care.  
Another workgroup is developing recommendations and guidelines 
regarding the appropriate role, responsibilities, and functions of Survey 
and Certification central and regional offices, State agencies, and other 
  OEI-06-06-00020  NURSING HOME EMERGENCY PREPAREDNESS AND RESPONSE DURING RECENT HURRICANES  23  R E C O M M E N D A T I O N S  
State and local emergency management entities to ensure a coordinated 
and effective emergency response. 
The full text of CMS comments is in Appendix E. 
  OEI-06-06-00020  NURSING HOME EMERGENCY PREPAREDNESS AND RESPONSE DURING RECENT HURRICANES  24    E N D N O T E S  

1 Government Accountability Office draft report, Evacuation of 
Hospitals and Nursing Homes (GAO-06-443R).  Preliminary findings 
reported in a briefing for congressional committees on February 16, 2006. 
2 Letter from Senator Herb Kohl, ranking member of the Special 
Committee on Aging, U.S. Senate, to Daniel R. Levinson, Inspector 
General, U.S. Department of Health and Human Services,        
September 26, 2005. 
3 Social Security Act, sections 1819(f)(1) and 1919(f)(1). 
4 42 CFR  483.75(m)(1) (plan) and (2) (training). 
5 State Operations Manual (SOM), Appendix PP, Interpretive 
Guidelines for Long Term Care Facilities, guidance for 483.75(m). 
6 Facilities may follow other standards, like those established by the 
Joint Commission on Accreditation of Healthcare Organizations 
(JCAHO), which accredits some nursing homes.  JCAHO 2006 Long Term 
Care Accreditation Standards for Emergency Management Planning.  
7  42 CFR  488.308 (survey frequency) and 42 CFR  488.330 
(certification and compliance). 
8 42 CFR  488.308(a), (e). 
9 42 CFR  483.75(m)(1) and (2); SOM, Appendix PP, Interpretive 
Guidelines for Long Term Care Facilities. 
10 State Operations Manual (SOM), Appendix PP, Interpretive 
Guidelines for Long Term Care Facilities, guidance for 483.75(m).  The 
guidelines provide guidance in  conducting surveys and clarify and/or 
explain the extent of the regulations. 
11 42 CFR  483.75(m)(1). 
12 42 CFR  483.75(m)(2). 
  OEI-06-06-00020  NURSING HOME EMERGENCY PREPAREDNESS AND RESPONSE DURING RECENT HURRICANES  25  13 42 CFR  488.110(a). 
14 The National Fire Protection Agency is a private, nonprofit 
organization dedicated to reducing loss of life due to fire. 
15 Social Security Act, sections 1819(d)(2) and 1919(d)(2).  
16 Draft Life Safety Code Survey Interpretive Guidelines to replace 
Appendix I of the SOM. 
17 Form CMS-2786R (03/04), Fire Safety Survey Report 2000 Code-
Health Care, Medicare/Medicaid. 
18 Robert T. Stafford Disaster Relief and Emergency Assistance Act, 42 
U.S.C.  5121(b)(2).  
19 Local and Tribal National Incident Management System Integration, 
1.0, U.S. Department of Homeland Security. 
20 Guide for All-Hazard Emergency Operations Planning (State/Local 
Guide 101), September 1996, Federal Emergency Management Agency. 
21 42 U.S.C.  3058g(a)(3)(G)(i).  The State Long Term Care 
Ombudsman Program is administered by the Administration on Aging. 
22 References to Gulf States throughout this report include Florida, 
Alabama, Mississippi, Louisiana, and Texas. 
23 Agency for Health Care Administration Emergency Management 
Planning Criteria for Nursing Homes (AHCA 3110-6006). 
24 Our selection excludes nursing homes that are currently under 
criminal investigation.  
25 Sources of guidance included interviews with emergency managers in 
all five Gulf States and with professors of emergency management from 
Oklahoma State University, Seton Hall University, and the University of 
North Texas, as well as professors of aging services from Florida 
International University.  Guidance was also drawn from published 
  OEI-06-06-00020  NURSING HOME EMERGENCY PREPAREDNESS AND RESPONSE DURING RECENT HURRICANES  26  works in The Gerontologist, Quick Response Research Report, Southern 
Medical Journal, and the American Journal of Public Health. 
26We counted each nursing home surveyed in 2004 and 2005 only once, 
although they were surveyed more than one time.  These figures 
represent all facilities that were cited with the relevant deficiencies, 
whether they had a single citation or multiple citations. 
27 Life Safety Code surveys focus on ensuring that facilities meet fire 
protection requirements designed to provide a reasonable degree of 
safety...the [requirement] covers construction and operational features 
designed to provide safety from fire, smoke, and panic.  Standard 
surveys assess: [c]ompliance with residents rights and quality of life 
requirements; [t]he quality of care and services furnished...; and [t]he 
effectiveness of the physical environment to empower residents, 
accommodate resident needs, and maintain resident safety.... (SOM, 
Appendix P.) 
28 We did not have the most recent survey data when we selected 
nursing homes. 
29 Based on discussions with Gulf State Surveyors in March 2006 and a 
review of CMS Form 2567. 
30 Both were in Mississippi, where State law requires that the decision 
to shelter in place or evacuate is made by local emergency managers.   
31 Emergency plans for 9 of the 20 selected homes included serving as a 
host facility for other facilities that evacuate. 
32 One of the destroyed facilities will be rebuilt, but owners of the other 
facility determined that it would remain closed.   
33 Special needs shelters are temporary shelters for those with physical 
or mental conditions that make it difficult to utilize a public shelter.   
34 Emergency Preparedness for Dialysis Facilities, CMS Manual 
11025, CMS, 2003. 
  OEI-06-06-00020  NURSING HOME EMERGENCY PREPAREDNESS AND RESPONSE DURING RECENT HURRICANES  27    A P P E N D I X   A  
Summary of Major Gulf State Requirements 
for Nursing Home Emergency Plans 
Table A1.  Gulf State Requirements for Nursing Home Emergency Plans 
State Requirements  AL*  FL  LA  MS  TX 
Community coordination  3  3  3  3 
Hazard analysis  3  3  3 
Communication  3  3  3 
Direction and control  3  3  3  3 
Specific resident needs  3  3  3 
Staffing  3  3  3 
Emergency food, water, supplies  3  3  3  3 
Emergency power  3  3  3 
Medications    3  3  3 
Evacuation procedures  3  3  3  3 
Evacuation route  3  3 
Transportation  3  3  3  3 
Host facility agreement  3  3  3  3 
Transfer of medical records  3  3 
Reentry  3  3 
Document training and drills   3  3  3  3 
Reviewed annually  3  3  3 
Staff telephone lists  3  3 
Responding to family inquiries  3  3 
Individual identification of residents  3 
Designated area for supply storage  3 
*Alabama relies on Federal requirements. 
Source:  Office of Inspector General analysis of State administrative code and requirements in four Gulf States, 2006. 
  OEI-06-06-00020  NURSING HOME EMERGENCY PREPAREDNESS AND RESPONSE DURING RECENT HURRICANES  28    A P P E N D I X   B  

A P P E N D I X   B  
DETAILED METHODOLOGY 
Identification of Hurricane Impacted Sites 
Hurricane-impacted sites were selected using information from the 
National Hurricane Center.  Information was reviewed for all 
hurricanes that made landfall along the U.S. border during 2004 and 
2005 and that were at least Category 3 strength on the Saffir-Simpson 
Scale, a 1  5 rating of intensity as measured by wind speed.  A 
Category 3 hurricane has winds of 111 to 130 miles per hour and 
anticipated storm surge of 9 to 12 feet above normal.  During the  
2 years specified there were a total of 10 hurricanes that made landfall 
in the United States and 7 were of significant strength to require mass 
evacuation. 
Four hurricanes in five States were selected for review:  Ivan in 
Alabama, Rita in Texas, and Katrina in Louisiana and Mississippi.  
Wilma was selected out of the four hurricanes in Florida because it was 
the most recent that met our criteria (see Appendix D for detailed 
information about each of the selected hurricanes). 
Site Selection 
The counties included in our site visits were selected based on proximity 
to where the hurricane made landfall.  To potentially identify 
differences within States, we made efforts to select two counties in each 
of the five states.  Table B1 provides community, hurricane, and nursing 
home information for each county. Our final selection was as follows: 
	 AlabamaBaldwin and Mobile Counties were both significantly 
impacted when hurricane Ivan came ashore in Baldwin County.   
	 FloridaCollier County is the location in Florida where hurricane 
Wilma made landfall. Lee County is directly north of Collier County 
and was chosen because of its proximity to Collier County and the 
high number of nursing homes located there.   
	 LouisianaSite selection in Louisiana was complicated by several 
factors.  Katrina first made landfall in Plaquemines Parish, but this 
site was excluded because there is only one nursing home.  St. 
Bernard Parish and Orleans Parish, the sites of numerous nursing 
home disasters, were excluded because most facilities were closed at 
the time of data collection.  Jefferson and St. Tammany Parishes 
were chosen because of their locationsboth experienced significant 
  OEI-06-06-00020  NURSING HOME EMERGENCY PREPAREDNESS AND RESPONSE DURING RECENT HURRICANES  29  A P P E N D I X   B  
impact from Katrina and had a sufficient number of nursing homes 
that were operational at the time of data collection.   
	 MississippiHancock and Harrison Counties were the most 
severely affected by Hurricane Katrina.  Hurricane Katrina made 
landfall at the border of Louisiana and Mississippi in Hancock 
County. 
	 TexasHarris County is near where Hurricane Rita made landfall 
and includes a large metropolitan area.  A second county was not 
selected because of the large size of Harris County and the option of 
selecting two distinct areas within this county for review.   
Table B1:  Selected Counties and Nursing Home Numbers 
Number of Nursing Homes 
State  County  Population*  Hurricane  Evacuate  Evacuate  No 
Before  After  Evacuation  Total 
AL  Baldwin  156,701  Ivan  2  0  4  6 
AL  Mobile  400,526  Ivan  2  0  14  16 
FL  Collier  296,678  Wilma  3  0  7  10 
FL  Lee  514,295  Wilma  2  0  16  18 
LA  Jefferson  453,590  Katrina  8  5  0  13 
LA  St. Tammany  213,553  Katrina  5  1  3  9 
MS  Hancock  45,933  Katrina  1  1  0  2 
MS  Harrison  192,393  Katrina  1  0  5  6 
TX  Harris  3,644,285  Rita  35  0  36  71 
TOTAL  59  7  85  151 
*Population information is based on 2004 Population Estimates from the U.S. Census Bureau. 
Source:  Office of Inspector General analysis of all nursing homes in selected counties, 2006. 
Facility Selection 
Twenty nursing homes (four in each state) were purposefully selected 
based on their diversity regarding a variety of factors, including size, 
ownership, and past State survey performance on emergency 
preparedness measures.  OSCAR data were used to obtain lists of 
nursing homes that had deficiencies for emergency preparedness in 
surveys conducted in 2003 and 2004.  We diversified the selection by the 
size of the facility, type of ownership, and whether it was a chain.   
(See Table B2 for nursing home details.)   
  OEI-06-06-00020  NURSING HOME EMERGENCY PREPAREDNESS AND RESPONSE DURING RECENT HURRICANES  30  A P P E N D I X   B  

Table B2.  Selected Nursing Home Characteristics 
Facility ID  Evacuate  Size  Ownership  Chain  County 
Alabama 1  Before  127  For-profit Corporation  Yes  Mobile 
Alabama 2  No  174  For-profit Individual  Yes  Mobile 
Alabama 3  Before  131  For-profit Corporation  Yes  Baldwin 
Alabama 4  No  75  Nonprofit Corporation  Yes  Baldwin 
Florida 1  Before  120  Nonprofit Other  No  Lee 
Florida 2  No  85  Nonprofit Corporation  No  Lee 
Florida 3  Before  97  For-profit Corporation  No  Collier 
Florida 4  No  117  For-profit Corporation  Yes  Collier 
Louisiana 1  Before  158  For-profit Corporation  Yes  Jefferson 
Louisiana 2  After  276  For-profit Corporation  Yes  Jefferson 
Louisiana 3  Before  116  For-profit Corporation  No  St. Tammany 
Louisiana 4  No  192  For-profit Corporation  Yes  St. Tammany 
Mississippi 1  Before  99  For-profit Partnership  No  Hancock 
Mississippi 2  After  132  For-profit Corporation  Yes  Hancock 
Mississippi 3  Before  180  For-profit Corporation  Yes  Harrison 
Mississippi 4  No  60  For-profit Corporation  Yes  Harrison 
Texas 1  Before  105  Nonprofit Corporation  No  Harris 
Texas 2  Before  120  For-profit Partnership  Yes  Harris 
Texas 3  Before  63  For-profit Corporation  No  Harris 
Texas 4  No  290  Nonprofit Corporation  No  Harris 
Source:  Information about facility size, ownership, chain status and location was obtained from the CMS Nursing 
Home Compare Web site, 2006. 
Within each State, we selected two facilities that evacuated and two 
that sheltered in place. We subsequently found that two of the facilities 
that sheltered in place during the hurricane evacuated after the storm, 
and one of the facilities that we thought sheltered in place actually 
evacuated before the storm. 
Data Collection 
Database. We used CMSs OSCAR database of State surveys to 
determine nursing homes in Gulf States and nationwide that received 
deficiencies in 2004 or 2005 for insufficient emergency plans and failure 
to adequately train staff for emergencies. OSCAR maintains 
information on the four most recent standard surveys of certified 
nursing facilities nationwide, as well as complaint-generated surveys.  
These data were obtained in March 2006. 
Site Visits. Two team members completed site visits to each of the five 
States to conduct interviews and collect documentary evidence. 
Interviews.  We visited 20 nursing homes4 in each of the 5 States.  We 
used a structured interview protocol to conduct onsite interviews with 
administrators, directors of nursing, certified nursing assistants, and 
  OEI-06-06-00020  NURSING HOME EMERGENCY PREPAREDNESS AND RESPONSE DURING RECENT HURRICANES  31  A P P E N D I X   B  
other staff that were involved in execution of the emergency plans.  We 
asked respondents about their emergency plans, staff training, 
evacuation orders during the specified hurricane, and what aspects of 
their plans contributed to positive and negative outcomes.  We asked 
nursing homes about their decisions to evacuate or shelter in place, and 
their experiences before, during, and in the aftermath of the hurricane. 
During each site visit, we also used a structured interview protocol to 
interview relevant municipal and other officials in each of the cities and 
counties. These respondents are detailed in Table B3.   
Interview questions included community emergency planning and 
response, the nature of evacuation orders, local requirements for 
nursing homes, assistance provided to nursing homes, implementation 
of emergency plans during the specified hurricane, and their reflections 
on the response of local nursing homes to the specified hurricane. 
Table B3.  Community Entity Respondents 
Respondent Affiliation*  Alabama  Florida  Louisiana  Mississippi  Texas  Total 
City Manager/Mayors Office  1  2  3  1  3  10 
County Emergency Managers  2  2  2  2  1  9 
City Emergency Managers  0  1  0  0  2  3 
Fire Department  2  2  4  3  2  13 
Police Department  2  2  1  2  1  8 
Area Agency on Aging  1  1  2  1  1  6 
Long Term Care Ombudsman  1  1  1  1  1  5 
Public Health Department  2  1  0  2  1  6 
Nursing Home Surveyors  0  0  1  0  0  1 
Total  11  12  14  12  12  61 
Source:  Office of Inspector General analysis of community officials where our selected nursing homes are located, 2006. 
*Totals reflect the number of respondent organizations.  Many organizations sent more than one representative. 
Documentary Evidence. At each of the 20 selected nursing homes, we 
obtained copies of emergency plans, transportation contracts, host 
agreements, training logs for 2005, and other relevant hurricane-related 
documents. We also obtained hurricane-related documents and copies 
of community emergency plans from community entity respondents in 
each of the locations of selected facilities. 
Telephone Interviews. We conducted telephone interviews with officials 
from State agencies for each of the five States where our selected 
nursing homes are located.  For each State, we interviewed officials 
from the emergency management office, the nursing home licensing 
division that surveys facilities, nursing home associations (often 
multiple), departments of aging services, and Long Term Care 
  OEI-06-06-00020  NURSING HOME EMERGENCY PREPAREDNESS AND RESPONSE DURING RECENT HURRICANES  32  A P P E N D I X   B  
Ombudsman Program. We used a structured interview protocol to ask 
questions about their roles and responsibilities for emergency planning, 
actions taken during the specified hurricane, the nature of evacuation 
orders, State nursing home requirements, and assistance provided to 
nursing homes for development and execution of emergency plans.  We 
requested and received copies of State Administrative Codes for nursing 
home emergency preparedness, model plans, guidance they provide to 
nursing homes, and other relevant documents. 
We also interviewed State surveyors to obtain information regarding 
how they review emergency plans and emergency training procedures, 
and how they determine deficiencies and their scope and severity. 
Data Analysis 
Quantitative Analysis. For our review of survey deficiencies, we used 
standard and complaint survey data from January 1, 2004, through 
December 31, 2005, to obtain frequencies for deficiencies F517, F518, 
K48, and K50.  Whenever possible, interview and documentary evidence 
data were quantified and entered into Microsoft Access or Microsoft 
Excel and analyzed quantitatively using frequencies. 
Qualitative Analysis. We analyzed interview responses and documentary 
evidence using qualitative analysis methods. 
	 Interview Responses.  Interview notes were entered into a Microsoft 
Access database, then reviewed to identify issues and themes. 
	 Documentary Evidence.  Each emergency plan, transportation contract, 
host agreement, and other documentation was reviewed by two 
analysts to determine whether they included the suggested provisions 
described in Table C1 of Appendix C. Analysts compared review 
results and conferred to reach consensus regarding discrepancies. 
	 Cross-Source Analysis.  Information from documentary evidence was 
compared with interview responses where relevant.  For example, 
responses regarding contracts were compared with documentary 
evidence of the contract. Interview responses were also compared 
across sources.  For example, the nature of the evacuation order as 
perceived by both community leaders and nursing home staff. 
Data Limitations 
Although steps were taken to diversify our selection of hurricanes, 
communities, and nursing homes, their purposive selection does not 
allow inference of results either to the Gulf States or the Nation. 
  OEI-06-06-00020  NURSING HOME EMERGENCY PREPAREDNESS AND RESPONSE DURING RECENT HURRICANES  33    A P P E N D I X   C  

Suggested Provisions for Nursing Home
Emergency Plans 
To assess the content of emergency plans from selected nursing homes, 
we compiled a list of suggested emergency plan provisions to compare to 
the actual plans.  We generated the list from our review of provisions 
suggested by a number of informed sources, listed by category below. 
Table C1 describes each of the suggested provisions and also indicates 
the number of selected nursing homes emergency plans that included 
that provision.  Each provision was suggested by at least two sources 
and most provisions were suggested by many of the sources.  
Informed sources used to compile the suggested provisions were: 
o State Requirements and Guidelines: State requirements were 
obtained from Florida Administrative Code, Chapter 59A; 
Mississippi Administrative Code, Section E; Louisiana Survey 
Criteria for Nursing Home Emergency Preparedness Plans HHS-
NH-06; and Texas Administrative Code, Title 40, Part 1, Chapter 
19, Subchapter D, Rule 19.326.   State guidelines were Floridas 
Agency for Health Care Administrations Emergency Management 
Planning Criteria for Nursing Homes, Mississippi Emergency 
Disaster Planning Criteria for Nursing Home Facilities and 
Personal Care Homes, and the Louisiana Model Nursing Home 
Emergency Plan. 
o Professional Associations:  Information from professional 
associations included the American Health Care Association; the 
Florida Health Care Association; a hurricane summit held in 
Tallahassee, Florida, in February 2006 sponsored by the John A. 
Hartford Foundation and the American Association of Retired 
Persons; and the 2006 Long Term Care Accreditation Standards for 
Emergency Management Planning issued by the Joint Commission 
on Accreditation of Healthcare Organizations. 
o Expert Interviews: Interview respondents included emergency 
management agency officials in Gulf States, professors of 
emergency management from Oklahoma State University, Seton 
Hall University, the University of North Texas, and professors of 
aging services from Florida International University. 
o Professional Publications:  Articles reviewed were from Quick 
Response Research Report, Southern Medical Journal, and 
American Journal of Public Health. 
  OEI-06-06-00020  NURSING HOME EMERGENCY PREPAREDNESS AND RESPONSE DURING RECENT HURRICANES  34  A P P E N D I X   C  

Table C1. Suggested Provisions Contained in 20 Selected Nursing Home Emergency Plans 
Number of 
Provision  Description of Provision 
Plans (n=20) 
General Provisions 
Details specific vulnerabilities of the facility, such as close proximity to 
Hazard Analysis  17 
water and low elevation; accounts for various threats to the facility. 
Establishes a command post in the facility; defines management for 
Direction and Control  15 
emergency operations. 
Decision Criteria  Includes factors to consider in deciding to evacuate or shelter in place.  11 
Communication  Specifies clear communication protocols and backup plans.  11 
Staff Family Members  Indicates whether staff family can shelter at the facility and evacuate.  7 
Community 
Procedures for working with local emergency manager; submitting plan.  7 
Coordination 
Specific Resident 
Contains lists that include resident medical and personal needs.  5 
Needs 
Provisions for Sheltering in Place 
Details measures to secure building against damage; especially for 
Securing the Facility  17 
facilities sheltering in place. 
Specifies backup power, including generators and accounts for 
Emergency Power  19 
maintaining a supply of fuel. 
Food Supply  Details the amounts and types of food on hand.  19 
Water Supply  Details having potable water available (recommended amounts vary).  18 
Staffing  Designates key personnel in emergencies and prepares assignments.  17 
Medication  Specifies maintaining extra pharmacy stocks of common medications.  15 
Serving as a host facility  Describes hosting procedures and details ensuring 24-hour operations.  9 
Provisions for Evacuation 
Transportation Contract  Includes current contract(s) with vendors for transportation.  17 
Evacuation Procedures  Details contingency plans, policies, roles, responsibilities, and procedures.  14 
Host Facility Agreement  Includes current contract(s) to facilities, relocation to like facilities.  14 
Food Supply  Describes adequate supply and logistical support for transporting food.  14 
Describes logistics for moving medicationsincluding specification for 
Medications  14 
moving them under the control of a registered nurse. 
Transfer of Medical  Details having the residents medical records available; describes logistics 
14 
Records  for moving medical records. 
Staffing  Specifies procedures to ensure staff accompany evacuating residents.  13 
Resident Personal 
Includes list of items to accompany residents.  12 
Belongings 
Identifies who authorizes reentry, procedures for inspecting facility, and 
Reentry  9 
details transportation from the host facility. 
Water Supply  Specifies amount of water taken and logistical support.  7 
Identifies evacuation routes and secondary routes, includes maps and 
Evacuation Route  5 
specifies expected travel time. 
Source:  Office of Inspector General analysis of content of expert interviews, professional publications, professional association guidance, and 
State regulations and review of 20 selected Gulf State nursing home emergency plans, 2006. 
  OEI-06-06-00020  NURSING HOME EMERGENCY PREPAREDNESS AND RESPONSE DURING RECENT HURRICANES  35    A P P E N D I X   D  
DESCRIPTIONS OF SELECTED HURRICANES 
Prior to selecting communities and nursing homes, we selected four 
hurricanes that affected the Gulf States during 2004 and 2005:  Ivan, 
Katrina, Rita, and Wilma (see Table E1 for hurricane characteristics).1 
Table D1.  Selected Hurricanes and Their Characteristics 
Name  Cat  Date  Location  Max  U.S.  Est.  Notice 
Surge  Rain  Deaths  Cost  Watch  Warning 
Ivan  3  09/16/04  Gulf Shores,  15 ft  3-7 in  25  $14.2  51 hrs  42 hrs 
Alabama  Billion 
Katrina  3  08/29/05  Louisiana/  28 ft  10-12 in  1,336  $75  44 hrs  32 hrs 
Mississippi Border  Billion 
Rita  3  09/24/05  Louisiana/Texas  15 ft  15 in  62  $10  58 hrs  40 hrs 
Border  Billion 
Wilma  3  10/24/05  Cape Romano,  8 ft  7 in  5  $12.2  38 hrs  32 hrs 
Florida  Billion 
Source:  National Weather Service, National Hurricane Center, 2006. 
Ivan. Ivan reached Category 5 strength 3 times before making landfall 
as a Category 3 hurricane just west of Gulf Shores, Alabama, on 
September 16, 2004, costing approximately $14.2 billion in damage.  
The eye diameter was 40-50 Nautical miles, resulting in high winds 
over a narrow area near the Alabama/Florida border.  The high surf and 
wind caused extensive damages to Innerarity Point and Orange Beaches 
in Alabama. 
Katrina. Katrina was the costliest and third deadliest hurricane in the 
United States since 1900, and one of the most devastating natural 
disasters in  U.S. history.  While in the Gulf of Mexico, Katrina reached 
Category 5 intensity; however, it weakened to Category 3 (just below the 
Category 4 threshold) when it made landfall near the Pearl River at the 
Louisiana/Mississippi border on August 29, 2005.  Over 1.2 million 
people along the Gulf coast from Louisiana to Alabama were under an 
evacuation order, but the number that actually evacuated is unknown. 
The storm surge penetrated at least 6 miles inland in many parts of 
coastal Mississippi and up to 12 miles inland along bays and rivers, 
crossing Interstate 10 in many locations.  Interstate 10 is often the 
barrier used for mandatory evacuation, with everything south being 
evacuated. In addition to the Gulf storm surge, Lake Ponchartrain rose 
1 National Weather Services National Hurricane Center Tropical Prediction Center, 2006. 
  OEI-06-06-00020  NURSING HOME EMERGENCY PREPAREDNESS AND RESPONSE DURING RECENT HURRICANES  36  A P P E N D I X   D  
and pushed several feet of water into communities along its 
northeastern shores, and strained the levee system in New Orleans. 
Eventually the levees were breached, flooding over 80 percent of New 
Orleans to depths up to 20 feet. 
An estimated 1,336 deaths have been directly or indirectly attributed to 
Katrina. As of December 2005, more than 4,000 persons were still 
reported missing, so it is probable that the number of direct fatalities 
may never be known.  Katrina left 3 million people without electricity, 
some for several weeks.  The economic ramifications have been 
widespread and could be long lasting. 
Rita. Rita also reached Category 5 strength over the Gulf of Mexico, 
weakening to Category 3 prior to making landfall near the 
Texas/Louisiana border on September 24, 2005. According to the 
National Weather Service, Rita produced a storm surge of 15 feet.  
In the wake of Katrina, the approach of Rita led to one of the largest 
evacuations in U.S. history.  The number of evacuees in Texas may have 
exceeded 2 million.  Seven fatalities were directly related to Rita, and an 
additional 55 indirectly related, including more than 20 evacuating 
nursing home residents killed in a bus accident. 
Wilma. Wilma made landfall in southwestern Florida near Cape 
Romano on October 24, 2005, as a Category 3 hurricane.  Coastal Collier 
County experienced storm surges up to 8 feet.  It moved quickly across 
southern Florida and damage was unusually widespread.  Not only was 
Wilma responsible for 5 deaths, it also caused the largest disruption of 
electrical service ever in Florida, with an estimated 98 percent of south 
Florida losing electrical service. 
  OEI-06-06-00020  NURSING HOME EMERGENCY PREPAREDNESS AND RESPONSE DURING RECENT HURRICANES  37  ..
A P PEN D
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AGENCY CO:MENTS
(~
DEPAR'fENJ"('F1IEALTH & HUMAN SERVICES
,~~~ Cenlers for Medicare & Medicaid Services
.,'i\G: ~S Administrator
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Washington, DC 20201
", .: .. ::.:~\ on
.~ Fl0 ~'.. \~ ~J ~'~:i':.. LJUL 2 8
. VC.\..l~' 2006
DATE:
TO: DaJel R. Levinson
IOnspfecftcor eGe noeraflInspector General ~ ~ A
Marka. MCClellan,M.D.,Ph.D~ / m~
FROM:
Administrator
SUBJECT: Offce of Inspector General Draft Report: "Nuring Home
Emergency Preparedess and Experiences Dung Recent
Hurrcaes," (OEI-06-06-00020)
Than you for the opportity to review and comment on the above referenced Offce of
Inspector General (OIG) draft report regarding nursing home preparedness in the Gulf
Staes during the recent hurcanes. The OIG's thorough assessment utilized multiple
sources of information, such as surey data both nationally and for the Gulf States
(Alabama, Florida, Louisiana, Mississippi, and Texas); on-site interviews of  nursing
home sta, local authorities and other staeholders; emergency plans for twenty selected
nursing homes that were afected by hurcanes in the five Gulf States; and a list of
suggested emergency preparedness provisions compiled from recommendations of a
varety of informed sources.
The Centers for Medicare and Medicaid Services (CMS) appreciates the contributions
and valuable input by the OIG to ensure resident and sta safety. We have reviewed your
findings and recommendations. Your recommendations are consistent with steps we are
already taking to improve emergency prepardness. Our plan of action to your
recommendations follows.
OIG Recommendation
CMS should consider strengthening Federal certfication stadards for nuring home
emergency plan by including requirements for specific elements of emergency planng.
eMS ResDonse
We concur. We have been reviewing our regulatory requirements and interpretive
guidelines to determine whether and how they can be strengthened. The OIG report is
extremely helpfu as we complete ths review. Regulatory changes may be undertaken as
a long-term strategy while other strategies can be taen in the short-term to ensure
resident and staf safety.
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Several workgroups within CMS have been reviewing.the curent Federal emergency
preparedness requiements to determine the most appropriate methods of improving the
preparedness stdards applicable to health care facilties. The CMS also paricipates in
the National Fire Protection Association (NFPA) and is supportng efforts by the NFPA
to promote enhanced preparedness. We are also in regular communication with States
and Accrediting Organations to determne the most effective approaches that will
improve preparedness, ensure the presence contingency plans, promote coordination with
State and local entities, and improve staff  training regarding emergency preparedness.
OIG Recommendation
CMS should encourage communication and collaboration between State and local
emergency entities and nursing homes.
eMS ResDonse
We concur. We are planing to implement a communication stategy to disseminate
policies, procedures, interpretive guidance, and other communcations with State Surey
Agencies (SAs), CMS Regional Offce~ and health care facilities. The CMS will
encourage State and local emergency agency. collaboration and coordination through such
communcations.
The CMS is also paricipating in several Deparent of  Heath and Human Services
(DHHS) and interagency workgroups that are developing recommendations and gudace
for improving coordination and collaboration among Federal, State and local emergency
entities. In parcular, the DHHS Long-Term Healthcare Working Group, supported by
the Deparent of  Homeland Security, includes representatives from varous emergency
response agencies, such as Federal Emergency Management Agency, National Disaster
Medcal System, Veterans Affairs, U.S. Coast Guard, Centers for Disease Control and
Prevention, Public Health Services, Admnistration on Aging, Admistration for
Children and Famlies, and CMS, as well as State Offce of Emergency Management and
health care provider associations representatives.
The purse of  ths workgroup is to review, assess and develop nationa definitions,
recommendations and tagets for aU aspects of  health care (both facilty and communty-
based) to address emergency planing, hazd mitigation, response and recovery.
Another workgroup, the CMS Surey and Certification Interagency Role and Integration
Workgroup, is in the process of developing recommendations and guidelines regarding
the appropriate role, responsibilties and functions of Survey and Certification Central
and Regional Offces, SAs, and other State and local emergency management entities to
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assist in the development and partnering that must occur to implement a coordinated,
collaborative and effective emergency response.
Page 3 - Daniel R. Levinson
Again, we than the OIG for their suggestions and welcome the opportunity to make such
improvements in the Medicae and Medicaid programs. These suggestions wiU be
incorporated into the implementation process for Medicare and Medicaid with a
consideration for the need to provide quality care to nursing home residents durng both
stable and disruptive events.
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OEI.06.06.00020 NURSING HOME EMERGENCY PREPAREDNESS AND RESPONSE DURING RECENT HURRICANES 40   A C K N O W L E D G M E N T S

This report was prepared under the direction of Judith V. Tyler, Regional 
Inspector General for Evaluation and Inspections of the Dallas regional 
office, and Kevin Golladay, Deputy Regional Inspector General of the 
Dallas regional office.  Other principal Office of Evaluation and 
Inspections staff who contributed include: 
Susan Wolfe, Ph.D., Project Leader 
Ruth Ann Dorrill, Team Leader 
Sarah Craren, Ph.D., Program Analyst 
Sandy Khoury, Program Specialist 
Mark Richardson, Program Specialist 
  OEI-06-06-00020  NURSING HOME EMERGENCY PREPAREDNESS AND RESPONSE DURING RECENT HURRICANES  41