Department of Health and Human Services


OFFICE OF 

INSPECTOR GENERAL 

NURSING HOME EMERGENCY 


PREPAREDNESS AND RESPONSE 


DURING RECENT HURRICANES


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. 
Δ EXECUTIVE SUMMAR 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 

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EXE CUTIVE S U MMAR 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 

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EXE CUTIVE S U MMAR Y

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. 

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EXE CUTIVE S U MMAR 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. 

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Δ T ABLE OF CONTENTS 

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

INTR O D U C T I ON ........................................... 1

FINDI NGS ................................................. 7

National and Gulf State Emergency Preparedness ............. 7

Decision to Evacuate or Shelter in Place ..................... 8

Problems in Evacuating and Sheltering in Place.............. 10

Evaluation of Selected Nursing Homes’ Emergency Plans ...... 16

Nursing Home Collaboration With Emergency Entities ....... 18

RECOM M E NDATI O NS ..................................... 21

 Agency Comments ..................................... 23

ENDN OTE S ............................................... 25

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

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

B: Detailed Methodology ................................ 29

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

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

E: Agency Comments ................................... 38

ACKN O W LEDGMENTS .................................... 41
Δ INTRODU C TION 

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. 

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INTROD UCT ION 

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 facility’s 

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 F517—“The 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 F518—“The 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 

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INTROD UCT ION 

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 K48—“There is a written plan for the protection of all patients and for 

their evacuation in the event of an emergency”; and 

o K50—“Fire 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 plan’s 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. 

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.\

INTROD UCT ION

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 Florida’s 

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 CMS’s 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 

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ana

INTROD UCT ION 

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 

Florida 

Louisi 

Mississippi Texas 

Hurricane Rita Hurricane Katrina 

Hurricane Ivan 

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 home’s 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. 

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INTROD UCT ION 

Evaluation of Nursing Home Emergency Plans—“Suggested 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 President’s Council on Integrity and 

Efficiency and the Executive Council on Integrity and Efficiency. 

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Δ 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 

Of the 16,125 nursing homes 

surveyed during 2004 and 2005, 

most met Federal standards, 

with 6 percent cited for planning 

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 

(n = 15,135) 

% Facilities 

(n = 15,011) 

% Facilities 

(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 

(n = 2,375) 

% Facilities 

(n = 2,379) 

% Facilities 

(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. 

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F I NDING S 

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. 

Multiple factors, including community evacuation 

orders, influenced the decision of selected 

nursing homes to evacuate or shelter in place 

Of the 20 nursing homes we 

selected for onsite evaluation, 

11 evacuated before the hurricane, 

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 

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F I NDING 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 storm’s 

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 

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F I NDING S 

evacuate in part because they were unable to locate enough space in 

other nursing homes to accommodate all residents. 

All 20 of the selected Gulf State nursing homes 

experienced problems, whether they evacuated 

or sheltered in place 

Administrators and staff in selected 

nursing homes reported a range of 

experiences, but similar problems 

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 

hurricane’s 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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F N D N G S

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 NDING S 

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 

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F I NDING S 

beds and supplies to accommodate residents, and did not have locks 

needed to protect residents with Alzheimer’s 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 

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 O E I - 0 6 - 0 6 - 0 0 0 2 0 NURSING H OME E MERGENCY P REPAREDNESS AND RESPONSE DURING RECENT HURRICANES 14 

FINDINGS 

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 facility’s 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.
F I NDING S 

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 health—a tree fell into the 

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F I NDING 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. 

Administrators and staff from selected nursing 

homes did not always follow emergency plans 

and plans often lacked suggested provisions 

All emergency plans from the 

20 selected nursing homes met 

Federal requirements on their most 

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 

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F I NDING S 

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 facility’s 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 resident’s mobility, mental 

status, and bowel/bladder control, and other factors pertinent to 

transportation, security and care needs, e.g., Alzheimer’s 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; 

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F I NDING 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. 

Lack of collaboration between State and local 

emergency entities and nursing homes impeded 

emergency planning and management 

Nursing home administrators, 

local emergency management 

authorities, and other 

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 

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F I NDING S 

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. 

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F N 0 N G S

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
Δ RECOMME NDA TIONS 

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 home’s 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. 

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R E C O MMENDA 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 Alzheimer’s 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 staff’s 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 CMS’s 

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 CMS’s 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 

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R E C O MMENDA 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 AoA’s 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 

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R E C O MMENDA 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. 

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Δ ENDNOTE 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). 

 OE I-06-06-00 020 NURSI N G H O M E E MERG E N CY P REPARE DNESS AND RE S PONSE DU R I N G RECE N T HURR I CANE S 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 CodeHealth 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 

 OE I-06-06-00 020 NURSI N G H O M E E MERG E N CY P REPARE DNESS AND RE S PONSE DU R I N G RECE N T HURR I CANE S 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. 

 OE I-06-06-00 020 NURSI N G H O M E E MERG E N CY P REPARE DNESS AND RE S PONSE DU R I N G RECE N T HURR I CANE S 27 
Δ APPENDIX 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. 

 OE I-06-06-00 020 NURSI N G H O M E E MERG E N CY P REPARE DNESS AND RE S PONSE DU R I N G RECE N T HURR I CANE S 28 
ΔAPP E N D I X B APPENDIX 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: 

• Alabama—Baldwin and Mobile Counties were both significantly 

impacted when hurricane Ivan came ashore in Baldwin County. 

• Florida—Collier 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. 

• Louisiana—Site 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 locations—both experienced significant 

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APP 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. 

• Mississippi—Hancock 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. 

• Texas—Harris 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 

State County Population* Hurricane 

Number of Nursing Homes 

Evacuate 

Before 

Evacuate 

After 

No 

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.) 

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APP 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 CMS’s 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 homes—4 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 

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APP 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/Mayor’s 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 

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APP 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. 

 OE I-06-06-00 020 NURSI N G H O M E E MERG E N CY P REPARE DNESS AND RE S PONSE DU R I N G RECE N T HURR I CANE S 33 
Δ APPENDIX 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 HHSNH-06; and Texas Administrative Code, Title 40, Part 1, Chapter 

19, Subchapter D, Rule §19.326. State guidelines were Florida’s 

Agency for Health Care Administration’s 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. 

 OE I-06-06-00 020 NURSI N G H O M E E MERG E N CY P REPARE DNESS AND RE S PONSE DU R I N G RECE N T HURR I CANE S 34 
APP E N D I X C 

Table C1. Suggested Provisions Contained in 20 Selected Nursing Home Emergency Plans 

Provision Description of Provision Number of 

Plans (n=20) 

General Provisions 

Hazard Analysis Details specific vulnerabilities of the facility, such as close proximity to 

water and low elevation; accounts for various threats to the facility. 17 

Direction and Control Establishes a command post in the facility; defines management for 

emergency operations. 15 

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 

Coordination Procedures for working with local emergency manager; submitting plan. 7 

Specific Resident 

Needs Contains lists that include resident medical and personal needs. 5 

Provisions for Sheltering in Place 

Securing the Facility Details measures to secure building against damage; especially for 

facilities sheltering in place. 17 

Emergency Power Specifies backup power, including generators and accounts for 

maintaining a supply of fuel. 19 

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 

Medications Describes logistics for moving medications—including specification for 

moving them under the control of a registered nurse. 14 

Transfer of Medical 

Records 

Details having the resident’s medical records available; describes logistics 

for moving medical records. 14 

Staffing Specifies procedures to ensure staff accompany evacuating residents. 13 

Resident Personal 

Belongings Includes list of items to accompany residents. 12 

Reentry 

Identifies who authorizes reentry, procedures for inspecting facility, and 

details transportation from the host facility. 9 

Water Supply Specifies amount of water taken and logistical support. 7 

Evacuation Route Identifies evacuation routes and secondary routes, includes maps and 

specifies expected travel time. 5 

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. 

 OE I-06-06-00 020 NURSI N G H O M E E MERG E N CY P REPARE DNESS AND RE S PONSE DU R I N G RECE N T HURR I CANE S 35 
Δ APPENDIX 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 

Surge Rain 

U.S. 

Deaths 

Est. 

Cost 

Notice 

Watch Warning 

Ivan 3 09/16/04 Gulf Shores, 

Alabama 

15 ft 3-7 in 25 $14.2 

Billion 

51 hrs 42 hrs 

Katrina 3 08/29/05 Louisiana/ 

Mississippi Border 

28 ft 10-12 in 1,336 $75 

Billion 

44 hrs 32 hrs 

Rita 3 09/24/05 Louisiana/Texas 

Border 

15 ft 15 in 62 $10 

Billion 

58 hrs 40 hrs 

Wilma 3 10/24/05 Cape Romano, 

Florida 

8 ft 7 in 5 $12.2 

Billion 

38 hrs 32 hrs 

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. 

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APP 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. 

 OE I-06-06-00 020 NURSI N G H O M E E MERG E N CY P REPARE DNESS AND RE S PONSE DU R I N G RECE N T HURR I CANE S 37 
.. A P PEN D x E

AGENCY CO:MENTS

(~,~~~

DEPAR'fENJ"('F1IÊALTH & HUMAN SERVICES Cenlers for Medicare & Medicaid Services

.,'i\G: ~S

. '; ..~ '. :",_ '3 ~,

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.~ Fl0 ~'.. \~ ~J ~'~:i':.. LJUL 2 8

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DATE:

Administrator

Washington, DC 20201

2006

TO: DaJel R. Levinson

Inspector General Offce ofInspector General ~ ~ A

Marka. MCClellan,M.D.,Ph.D~ / m~

Administrator

FROM:

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.

OEI.06.06.00020 NURSING HOME EMERGENCY PREPAREDNESS AND RESPONSE DURING RECENT HURRICANES 38
A P PEN D x E

Page 2 - Daniel R. Levinson

Several workgroups within CMS have been reviewing.the curent Federál 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 communtybased) 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

2

OEI.06.06.00020 NURSING HOME EMERGENCY PREPAREDNESS AND RESPONSE DURING RECENT HURRICANES 39
A P PEN D x E

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.

3

OEI.06.06.00020 NURSING HOME EMERGENCY PREPAREDNESS AND RESPONSE DURING RECENT HURRICANES 40
Δ ACKNOWLEDGMENTS

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 

 OE I-06-06-00 020 NURSI N G H O M E E MERG E N CY P REPARE DNESS AND RE S PONSE DU R I N G RECE N T HURR I CANE S 41