United States Government Accountability Office

GAO Report to Congressional Committees

DISASTER 

PREPAREDNESS 

Limitations in Federal 

Evacuation Assistance 

for Health Facilities 

Should be Addressed 

July 2006 

 

GAO-06-826 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

July 2006

DISASTER PREPAREDNESS 

Limitations in Federal Evacuation 

Assistance for Health Facilities Should be 

Addressed 

Highlights of GAO-06-826, a report to 

congressional committees 

Hurricane Katrina demonstrated

difficulties involved in evacuating

communities and raised questions 

about how hospitals and nursing 

homes plan for evacuations and 

how the federal government

assists. Due to broad-based 

congressional interest, GAO 

assessed the evacuation of hospital 

patients and nursing home 

residents. Under the Comptroller

General’s authority to conduct 

evaluations on his own initiative, 

GAO examined (1) the challenges

hospital and nursing home 

administrators faced, (2) the extent 

to which limitations exist in the

design of the National Disaster

Medical System (NDMS) to assist 

with patient evacuations, and 

(3) the federal requirements for

hospital and nursing home disaster

and evacuation planning. GAO 

reviewed documents and 

interviewed federal officials, and 

interviewed hospital and nursing 

home administrators and state and 

local officials in areas affected by

Hurricane Katrina in Mississippi 

and Hurricane Charley in Florida.

What GAO Recommends

GAO recommends that DHS clearly 

delineate (1) how the federal 

government will assist state and 

local governments with the 

transportation of patients and 

residents out of hospitals and 

nursing homes, and (2) how to 

address the needs of nursing home 

residents during evacuations. In its 

comments, DHS stated that it will 

take the recommendations under

advisement as it revises the NRP. 

Hospital and nursing home administrators faced several challenges related 

to evacuations during recent hurricanes, including deciding whether to 

evacuate or stay in their facilities and “shelter in place”, obtaining 

transportation necessary for evacuations, and maintaining communication 

outside of their facilities. Administrators took steps to ensure that their 

facilities had needed resources—including staff, supplies, food, water, and 

power—to provide care during the hurricane and maintain self-sufficiency

immediately after. However, when evacuations were needed, facility 

administrators said that they had problems with transportation, such as 

securing the vehicles needed to evacuate patients. Although facility 

administrators had contracts with transportation companies, competition for 

the same pool of vehicles created supply shortages when multiple facilities 

in a community had to be evacuated. In addition, communication was 

impaired by hurricane damage. For example, a nursing home in Florida was 

unable to communicate with local emergency managers. 

NDMS is a partnership of four federal agencies, and has two limitations in its 

design that constrain its assistance to state and local governments with 

patient evacuation. The NDMS partners are the Department of Defense, the 

Department of Health and Human Services (HHS), the Department of 

Homeland Security (DHS), and the Department of Veterans Affairs; DHS is 

the lead agency. The first limitation is that NDMS evacuation efforts begin at 

a mobilization center, such as an airport, and do not include short-distance 

transportation assets, such as ambulances or helicopters, to move patients 

out of health care facilities to mobilization centers. The second limitation is 

that NDMS supports the evacuation of patients needing hospital care; the 

program was not designed nor is it currently configured to move people who 

do not require hospitalization, such as nursing home residents. Although 

NDMS moved nursing home residents due to Hurricane Katrina who were 

brought to mobilization centers, NDMS officials had to make special 

arrangements for people in need of nursing home care because NDMS 

lacked preexisting agreements with nursing homes. Neither of these 

limitations is addressed in other documents GAO reviewed, including DHS’s 

National Response Plan (NRP). 

At the federal level, HHS’s Centers for Medicare & Medicaid Services (CMS) 

has requirements related to hospital and nursing home evacuation planning 

as a condition of participation in the Medicare and Medicaid programs. CMS 

requires that hospitals maintain the overall hospital environment to assure 

patient safety, including developing plans that consider the transfer of 

patients to other health care settings. For nursing homes, CMS requires that 

plans meet all potential emergencies and disasters; however, requirements 

do not specifically mention the transfer of residents. In addition to assessing 

compliance with CMS requirements, the Joint Commission on Accreditation 

of Healthcare Organizations, the American Osteopathic Association, and 

states can also have additional emergency management requirements. 

www.gao.gov/cgi-bin/getrpt?GAO-06-826.

To view the full product, including the scope 

and methodology, click on the link above. 

For more information, contact Cynthia A. 

Bascetta at (202) 512-7101 or 

bascettac@gao.gov. 
Contents 

Letter 1

Results in Brief 4

Background 6

Facility Administrators Faced Several Challenges Related to 

Evacuation, Including Deciding Whether to Evacuate, Securing 

Transportation, and Maintaining Communication 11 

NDMS Has Two Limitations That Constrain Its Assistance to State 

and Local Governments with Patient Evacuation and Which Are 

Not Addressed Elsewhere in the NRP 15 

Federal Requirements for Hospitals and Nursing Homes Include 

Provisions for Having Disaster Plans and Transferring Patients

Out of Hospitals 17 

Conclusions 18

Recommendations for Executive Action 19 

Agency Comments and Our Evaluation 20 

Appendix I Scope and Methodology 24 

Appendix II CMS Regulations and Interpretive Guidelines 

Related to Hospital and Nursing Home Disaster and 

Evacuation 27 

Appendix III JCAHO and AOA Requirements for Hospital 

Evacuation Planning and Emergency Preparedness 30 

Appendix IV Comments from the Department of Homeland 

Security 44 

Appendix V Comments from the Department of Defense 46 

Page i GAO-06-826 Evacuation of Hospitals and Nursing Homes
Appendix VI Comments from the Department of Health and 

Human Services 48 

Appendix VII Comments from the Department of Veterans Affairs 49 

Appendix VIII GAO Contact and Staff Acknowledgments 50 

Related GAO Products 51 

Tables 

Table 1: CMS Regulation and Interpretive Guidelines for Hospitals 27 

Table 2: CMS Guidance to Surveyors for Long Term Care Facilities 29 

Table 3: 2005 AOA Accreditation Requirements for Hospitals 41 

Page ii GAO-06-826 Evacuation of Hospitals and Nursing Homes
Abbreviations 

AOA American Osteopathic Association 

CMS Centers for Medicare & Medicaid Services 

DHS Department of Homeland Security 

DMAT Disaster Medical Assistance Team 

DOD Department of Defense 

DOT Department of Transportation 

EOC emergency operations center 

ESF emergency support function 

FEMA Federal Emergency Management Agency 

HHS Department of Health and Human Services 

JCAHO Joint Commission on Accreditation of Healthcare 

 Organizations 

NDMS National Disaster Medical System 

NRP National Response Plan 

QAPI quality assessment performance improvement 

VA Department of Veterans Affairs 

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Page iii GAO-06-826 Evacuation of Hospitals and Nursing Homes
United States Government Accountability Office

Washington, DC 20548 

July 20, 2006

Congressional Committees 

On August 29, 2005, Hurricane Katrina struck near the LouisianaMississippi border and became one of the worst natural disasters in U.S. 

history. Hurricane Katrina affected a large geographic area and 

necessitated the evacuation of parts of the area. Among those needing to

be evacuated were people in health care facilities such as hospitals and 

nursing homes. During disasters such as Hurricane Katrina, administrators 

of hospitals or nursing homes must make decisions about the best way to

care for their patients or residents under such circumstances, including 

whether to evacuate if the facility becomes unable to support adequate 

care, treatment, or other services.1

 Moreover, if administrators decide to 

evacuate, hospital patients or nursing home residents may need special

equipment or have other complicating factors which inhibit their 

movement, thereby increasing the risk to their safety during the 

evacuation process. Due to Hurricane Katrina, efforts were made to 

evacuate hospital patients and nursing home residents. In the storm’s 

aftermath, congressional reports raised questions about how health care 

facility administrators plan for hurricanes, how they implement their 

plans, and how the federal government assists health care facilities and 

state and local governments with facility evacuations.2

Federal, state, and local governments, as well as individual health care 

facilities, have plans for how they will respond to emergencies such as 

hurricanes. At the federal level, the National Response Plan (NRP)3

provides a framework for how the federal government is to assist states 

and localities in managing domestic incidents, including both incidents of 

 1

For our purposes, evacuation refers to moving all hospital patients or nursing home 

residents out of both the facility and the affected area. 

2

See U.S. House of Representatives, A Failure of Initiative: Final Report of the Select

Bipartisan Committee to Investigate the Preparation for and Response to Hurricane

Katrina (Feb. 15, 2006). See also Committee on Homeland Security and Governmental 

Affairs, U.S. Senate, Hurricane Katrina: A Nation Still Unprepared (May 2006). 

3

This report reflects the NRP as updated on May 25, 2006. 

Page 1 GAO-06-826 Evacuation of Hospitals and Nursing Homes
national significance and those of lesser severity.4

 A program identified in 

the NRP, the National Disaster Medical System (NDMS), can assist state 

and local governments with evacuations of patients who need hospital 

care.5

 NDMS is a partnership of four federal agencies, and the Department 

of Homeland Security (DHS) is the lead agency.

6

 At the state and local

levels, governments often have comprehensive emergency management 

plans that mirror the NRP. At the individual facility level, hospitals and 

nursing homes that participate in the Medicare and Medicaid programs 

must comply with requirements established by the Department of Health

and Human Services’ (HHS) Centers for Medicare & Medicaid Services 

(CMS).7

 Compliance with these requirements is assessed by accrediting 

organizations such as the Joint Commission on Accreditation of 

Healthcare Organizations (JCAHO) and the American Osteopathic 

Association (AOA), and state agencies. 

Due to broad-based congressional interest, we assessed the evacuation of

hospital patients and nursing home residents due to hurricanes. We 

performed this work under the Comptroller General’s authority to conduct 

evaluations on his own initiative.8

 In February 2006, we reported on 

 4

Under the NRP, the Secretary of Homeland Security will consider, but is not limited to, the

four criteria stated in Homeland Security Presidential Directive 5 (HSPD-5) when deciding 

whether to declare an incident of national significance. These criteria are: (1) a federal 

department or agency acting under its own authority has requested the assistance of the 

Secretary of Homeland Security, (2) the resources of state and local authorities are 

overwhelmed and federal assistance has been requested by the appropriate state and local 

authorities, (3) more than one federal department or agency has become substantially 

involved in responding to an incident, or (4) the Secretary of Homeland Security has been 

directed to assume responsibility for managing a domestic incident by the President. 

5

Public Health Security and Bioterrorism Preparedness and Response Act of 2002, Pub. L.

No. 107-188, § 102(a), 116 Stat. 595, 599 (formally establishing a program otherwise in 

operation since 1984; to be codified at 42 U.S.C. § 300hh-11). 

6

The NDMS partners are DHS, Department of Health and Human Services (HHS),

Department of Veterans Affairs (VA), and Department of Defense (DOD). The Homeland 

Security Act of 2002 transferred overall NDMS responsibility to DHS from HHS. Pub. L. No. 

107-296, § 503(5), 116 Stat. 2135, 2213 (codified at 6 U.S.C. § 313(5)). H.R. 5438, 109th Cong. 

(2006), which was introduced May 22, 2006, would transfer overall NDMS responsibility 

back to HHS. 

7

CMS issues interpretive guidelines that contain authoritative interpretations and

clarifications of statutory and regulatory provisions, and these are to be used to make

compliance determinations. Throughout this report, we refer to both CMS regulations and

interpretive guidelines as “requirements.” 

8

31 U.S.C. § 717(b)(1) (2000). 

Page 2 GAO-06-826 Evacuation of Hospitals and Nursing Homes
preliminary observations from our work,9

 and in May 2006, we testified on 

our preliminary observations before the Senate Special Committee on 

Aging.10 To complete our assessment, we examined (1) the challenges 

hospital and nursing home administrators faced related to recent 

hurricanes, (2) the extent to which limitations exist in the design of NDMS 

or other federal programs to assist state and local governments with 

patient evacuations, and (3) the federal requirements for hospital and 

nursing home disaster and evacuation planning. 

For our first objective related to the challenges hospital and nursing home 

administrators faced related to recent hurricanes, we reviewed 

documents, including emergency management plans from state and local 

governments and hospitals and nursing homes in Florida and Mississippi. 

We interviewed officials in Mississippi who experienced Hurricane 

Katrina, including officials from five hospitals, three nursing homes and 

assisted living facilities, state officials, and local emergency management 

officials in two counties. We also interviewed officials in Florida in areas 

that experienced hurricanes in 2004, particularly those affected by 

Hurricane Charley, which was the strongest hurricane to hit the United 

States since Andrew hit southern Florida in 1992.11 In Florida, we spoke 

with officials from three hospitals and three nursing homes, state officials, 

and local emergency management officials in two counties. We also 

interviewed officials from national hospital and nursing home 

associations, Florida hospital and nursing home associations, and a 

Mississippi nursing home association. For our second objective 

concerning the extent to which limitations exist in the ability of NDMS or 

other federal programs to assist state and local governments with patient 

evacuations, we reviewed federal documents such as the NRP, including

the September 2005 draft Catastrophic Incident Supplement to the NRP. 

We also interviewed officials from the Department of Defense (DOD), 

HHS, DHS, the Department of Transportation (DOT), and the Department 

of Veterans Affairs (VA), including officials who are responsible for NDMS,

 9

GAO, Disaster Preparedness: Preliminary Observations on the Evacuation of Hospitals 

and Nursing Homes Due to Hurricanes, GAO-06-443R (Washington, D.C.: Feb. 16, 2006).

Also see related GAO products at the end of this report. 

10GAO, Disaster Preparedness: Preliminary Observations on the Evacuation of 

Vulnerable Populations due to Hurricanes and Other Disasters, GAO-06-790T 

(Washington, D.C.: May 18, 2006). 

11Hurricane Charley struck the Gulf Coast of Florida on August 13, 2004. The hurricane

continued across Florida to exit the state on the Atlantic Coast on August 14, 2004. 

Page 3 GAO-06-826 Evacuation of Hospitals and Nursing Homes
asking about moving patients out of facilities and out of the affected areas. 

For our third objective on federal requirements for hospital and nursing 

home disaster and evacuation planning, we reviewed CMS documents 

describing hospital and nursing home emergency planning requirements 

that specifically relate to evacuations. We also interviewed officials from 

CMS, JCAHO, and AOA concerning these requirements, as well as officials 

from national hospital and nursing home associations, Florida hospital and 

nursing home associations, and a Mississippi nursing home association. In 

addition, we interviewed officials and obtained documents from the 

Florida Agency for Healthcare Administration and Mississippi Department 

of Health concerning state hospital and nursing home requirements for 

evacuation. For additional information on our scope and methodology, see 

appendix I. Our work was performed from October 2005 through July 2006 

in accordance with generally accepted government auditing standards. 

Hospital and nursing home administrators faced several challenges related 

to evacuations during recent hurricanes, including deciding whether to 

evacuate or stay in their facilities and “shelter in place”, obtaining 

transportation necessary for evacuations, and maintaining communication 

outside of their facilities. Administrators said they generally prefer to 

shelter in place, but when doing so they must have sufficient resources to 

provide care during a hurricane, and maintain self-sufficiency immediately 

after a hurricane to continue to care for patients until help can arrive. For

example, during hurricanes Katrina and Charley, administrators had to 

ensure that their facilities had needed resources, including staff who could 

stay at the facility for 3 or more days; sufficient food, water, and supplies 

to account for the inability to replenish resources during the hurricane; 

and power, which required having enough fuel to run generators for 

multiple days. When evacuations were needed, facility administrators said 

that they had problems with transportation, such as securing the vehicles 

needed to evacuate patients. Although facilities had contracts with 

transportation companies, competition for the same pool of vehicles 

created supply shortages. In addition, communication was impaired by 

hurricane damage to the local infrastructure. For example, a nursing home 

in Florida was unable to communicate with local emergency managers. 

Results in Brief 

NDMS has two limitations in its design that constrain its assistance to 

state and local governments with patient evacuation, and which are not 

addressed elsewhere in the NRP. The first limitation is that NDMS 

evacuation efforts begin at a mobilization center, such as an airport, and 

do not include short-distance transportation assets, such as ambulances or 

helicopters, to move patients out of health care facilities to mobilization 

Page 4 GAO-06-826 Evacuation of Hospitals and Nursing Homes
centers. Moreover, based on the documents we reviewed, including the 

NRP, we found that there are no other federal programs that assist with 

this transportation function. The second limitation is that NDMS supports 

the evacuation of patients needing hospital care; the program was not 

designed nor is it currently configured to move people who do not require 

hospitalization, such as nursing home residents. Although NDMS moved 

nursing home residents during Hurricane Katrina who were brought to 

mobilization centers, NDMS officials had to make special arrangements for 

people in need of nursing home care because NDMS lacked preexisting 

agreements with nursing homes. The movement of nursing home residents 

during evacuations is not addressed elsewhere in the NRP. 

At the federal level, CMS has requirements related to hospital and nursing 

home disaster and evacuation planning as a condition of participation in 

the Medicare and Medicaid programs. For hospitals, CMS requires that the 

overall hospital environment must be maintained to assure the safety and 

well-being of patients. According to CMS guidelines for interpreting this 

regulation, hospitals must develop and maintain comprehensive 

emergency plans, and when developing plans, should consider the transfer 

of patients to other health care settings or hospitals if necessary. For 

nursing homes, CMS requires that facilities must have plans to meet all 

potential emergencies and disasters, although CMS guidelines for 

interpreting the regulation do not specifically mention transfer of 

residents. In addition, JCAHO, AOA, and states can also have additional 

emergency management requirements. For example, JCAHO requires that 

hospitals it accredits have emergency plans that include provisions for 

evacuating the entire building and transporting patients, supplies, staff, 

and equipment to alternate care sites if necessary. 

We are recommending that DHS clearly delineate how the federal 

government will assist state and local governments with the transportation 

of patients and residents out of hospitals and nursing homes to a 

mobilization center where NDMS evacuation begins. We further 

recommend that DHS, in consultation with the three other NDMS partners, 

clearly delineate how to address the needs of nursing home residents 

during evacuations, including the arrangements necessary to relocate 

these residents. 

We received written comments on a draft of this report from DHS, DOD, 

HHS, and VA. DHS stated that it will take our recommendations under 

advisement as it reviews the National Response Plan. According to DHS, 

all of the NDMS federal partners are currently reviewing the NDMS 

memorandum of agreement with a view toward working with state and 

Page 5 GAO-06-826 Evacuation of Hospitals and Nursing Homes
local partners to alter, delineate, and otherwise clarify roles and 

responsibilities as appropriate. HHS and VA generally agreed with our 

recommendations. DOD disagreed with our conclusion regarding NDMS 

limitations, noting that state and local governments are responsible for the 

provision of short-distance transportation, rather than it being a federal 

responsibility. However, DHS confirmed that while the primary 

responsibility for evacuations remains with state and local governments, 

the federal government becomes involved when the capabilities of the 

state and local governments are overwhelmed, as we reported. We 

therefore believe that it is important for DHS to clearly delineate how the 

federal government will assist state and local governments in these 

instances. 

At the federal level, the NRP provides a framework for how the federal 

government is to assist states and localities in managing emergencies and 

major disasters. NDMS is one of the programs identified in the NRP that 

can supplement state and local medical resources during emergencies, 

including providing resources to assist with evacuation. At the individual 

facility level, hospitals and nursing homes must comply with CMS 

requirements to participate in the Medicare and Medicaid programs. 

Several recently issued federal reports have looked at the adequacy of 

health care facility disaster planning, as prompted by Hurricane Katrina. 

In December 2004, DHS issued the NRP to consolidate existing federal 

government emergency response plans into a single coordinated plan, as 

mandated by the Homeland Security Act of 2002.12 The NRP provides a 

framework for how the federal government is to assist states and localities 

in managing domestic incidents, including an “emergency”13 or a “major 

Background 

The National Response 

Plan 

 12Pub. L. No. 107-296, § 502(6), 116 Stat. 2135, 2212-13 (to be codified at 6 U.S.C. § 312(6)). 

The NRP supersedes other federal emergency planning documents, including the Initial 

National Response Plan and the Federal Response Plan. 

13An emergency is defined as any occasion or instance for which, in the determination of

the President, federal assistance is needed to supplement state and local efforts and 

capabilities to save lives and to protect property and public health and safety, or to lessen 

or avert the threat of a catastrophe in any part of the United States. 42 U.S.C. § 5122(1)

(2000). 

Page 6 GAO-06-826 Evacuation of Hospitals and Nursing Homes
disaster”14 declared by the President under the Robert T. Stafford Disaster

Relief and Emergency Assistance Act (Stafford Act).15 On May 25, 2006, 

DHS revised the NRP to address certain weaknesses or ambiguities 

identified following Hurricane Katrina.16

The NRP includes a Catastrophic Incident Annex, which provides for an 

accelerated, proactive national response to catastrophic incidents—

defined as any natural or manmade incident, including terrorism, resulting 

in extraordinary levels of mass casualties, damage, or disruption severely

affecting the population, infrastructure, environment, economy, national 

morale, and/or government functions.17 By definition, a catastrophic 

incident almost immediately exceeds resources normally available to 

state, local, tribal, and private-sector authorities in the impacted area. A 

separate Catastrophic Incident Supplement, which was drafted but had 

not been approved at the time of Hurricane Katrina, provides additional 

detail on the roles and responsibilities of federal, state, and local 

responders during catastrophic incidents. However, as of June 2006, the 

supplement had not been finalized. 

Among its many components, the NRP establishes 15 emergency support 

functions (ESF), which identify resources and define the missions and 

 14Major disaster is defined as any natural catastrophe or, regardless of cause, any fire, 

flood, or explosion, in any part of the United States, which in the determination of the

President causes damage of sufficient severity and magnitude to warrant major disaster 

assistance under the Stafford Act to supplement the efforts and available resources of

states, local governments, and disaster relief organizations in alleviating damage, loss, 

hardship, or suffering. 42 U.S.C. § 5122(2) (2000). 

15Pub. L. No. 93-288, 88 Stat. 143 (1974) (codified as amended at 42 U.S.C. §§ 5121-5206). 

The Stafford Act primarily establishes the programs and processes the federal government 

uses to provide emergency and major disaster assistance to states, local governments, 

tribal nations, individuals, and qualified private nonprofit organizations. 

16The revised NRP makes clear that the Secretary of Homeland Security is responsible for 

declaring and managing incidents of national significance such as Hurricane Katrina.

Incidents of lesser severity requiring federal involvement are also subject to the NRP, but

implementation of the NRP is to be scaled and flexible depending on the nature of the

event. 

17The responsibility for determining whether an incident of national significance meets the

NRP’s definition of a “catastrophic incident” rests with the Secretary of Homeland Security. 

The Secretary makes a “catastrophic incident” designation to activate the provisions of the

annex. The Secretary declared Hurricane Katrina an incident of national significance on 

August 30, 2005, but never declared it a catastrophic incident. The revised NRP makes 

explicit that the Secretary could activate the annex to address events that are projected to 

mature to catastrophic proportions, such as strengthening hurricanes. 

Page 7 GAO-06-826 Evacuation of Hospitals and Nursing Homes
responsibilities of various federal agencies in helping coordinate support 

during incidents of national significance. For each of the NRP’s 15 ESFs, 

which include Transportation, Communications, Firefighting, and Public

Health and Medical Services, the NRP designates a federal agency as the 

ESF coordinator responsible for pre-incident planning and coordination. It

also designates one or more primary agencies to be responsible for 

operational priorities and activities, coordinating with other agencies and 

state partners, and planning for incident management. HHS, for example, 

is designated as the ESF coordinator and the primary agency for ESF #8—

Public Health and Medical Services. 

The National Disaster 

Medical System 

NDMS, one of the programs included in ESF #8—Public Health and 

Medical Services—of the NRP, was formed in 1984 to care for massive 

numbers of casualties generated in a domestic disaster or an overseas 

conventional war. It is a nationwide medical response system to 

supplement state and local medical resources during disasters and 

emergencies and to provide back-up medical support to the military and 

VA health care systems during an overseas conventional conflict. DOD, 

HHS, DHS, and VA are federal partners in NDMS. These partners most 

recently signed a memorandum of agreement in October 2005 that 

describes the roles and responsibilities of each partner. DHS has the 

authority to activate NDMS in response to public health emergencies, 

which include, but are not limited to, presidentially declared emergencies

or major disasters under the Stafford Act. 

NDMS consists of three key functions: 

• medical response, which includes medical equipment and supplies, patient 

triage, and other emergency health care services provided to disaster 

victims at a disaster site through NDMS medical response teams such as 

Disaster Medical Assistance Teams (DMAT);18

• patient evacuation, which includes communication and transportation to 

evacuate patients from a mobilization center near the disaster site, such as 

an airport, to reception facilities in other locations; and 

• “definitive care,” which is additional medical care—beyond emergency 

care—that begins once disaster victims are placed into an NDMS inpatient 

 18A Disaster Medical Assistance Team (DMAT) is a group of medical and support personnel 

designated to provide medical care during disasters. DMATs are designed to deploy to 

disaster sites with sufficient supplies and equipment, and their responsibilities may include

triaging patients and preparing patients for evacuation. 

Page 8 GAO-06-826 Evacuation of Hospitals and Nursing Homes
treatment facility (typically a nonfederal hospital that has signed an 

agreement with NDMS). 

DHS has lead responsibility for the medical response function of NDMS.

DOD takes the lead in coordinating patient evacuation for NDMS, in 

collaboration with DOT, the other NDMS federal partners, and commercial 

transportation companies. VA and DOD share lead responsibility for 

arranging definitive care, including tracking the availability of beds in 

hospitals that participate in NDMS.19

NDMS was used to supplement state and local patient evacuation efforts 

during Hurricane Katrina and Hurricane Rita, which struck the Gulf Coast 

several weeks after Hurricane Katrina. NDMS officials told us that 

Hurricane Katrina was the first time that the patient evacuation and 

definitive care components of NDMS were used for a large number of 

patients. In response to state requests for assistance, NDMS moved people 

from Louisiana after Hurricane Katrina and from Texas before Hurricane 

Rita. In total, about 2,900 people were transported to NDMS patient 

reception areas due to the two hurricanes. 

CMS establishes federal regulations that hospitals and nursing homes must 

meet to participate in the Medicare and Medicaid programs.20 These 

regulations relate to many aspects of hospital or nursing home operations, 

such as health care services, dietetic services, and physical environment, 

including emergency management. Hospitals that are accredited by 

JCAHO or AOA are generally deemed to meet most of these Medicare and 

Medicaid requirements;21 no organizations have similar deeming authority 

for nursing homes.22 State agencies survey and certify nursing homes and 

nonaccredited hospitals to ensure that they follow CMS requirements. 

CMS provides guidance to state agencies in the CMS State Operations 

Manual, which includes interpretive guidelines and survey procedures for 

Regulation of Hospitals 

and Nursing Homes 

 19Participating hospitals regularly report the number of beds that they have available for 

NDMS patients so that VA and DOD can quickly identify bed capacity when needed. 

2042 C.F.R. pts. 482 (for hospitals) and 483 (for nursing homes) (2005).

2142 U.S.C. § 1395bb (2000). 

22In 2004, JCAHO accredited approximately 4,666 hospitals, which represented about 

95 percent of all U.S. hospital beds. AOA accredits 165 hospitals. 

Page 9 GAO-06-826 Evacuation of Hospitals and Nursing Homes
state agencies to assess compliance with CMS regulations.23 In addition to 

CMS requirements, JCAHO, AOA, and states can establish additional 

requirements for hospitals and nursing homes. 

A number of federal reports address the issue of evacuation and health 

care facility disaster planning. These reports have in various ways called 

for improvements in coordination. The White House report on lessons 

learned from the federal response to Hurricane Katrina recommended that 

agencies coordinate together to plan, train, and conduct exercises to 

evacuate patients when state and local agencies are unable to do so in a 

timely or effective manner.24 The House of Representatives Select 

Bipartisan Committee to Investigate the Preparation for and Response to 

Hurricane Katrina reported that medical care and evacuations suffered 

from a lack of advance preparations, inadequate communications, and 

difficulties in coordinating efforts.25 The select committee’s report and a 

DHS Office of Inspector General Performance Review of the Federal 

Emergency Management Agency (FEMA) both noted that search and

rescue efforts during Hurricane Katrina were effective but could have

benefited from improved coordination among federal agencies.26 The 

Senate Committee on Homeland Security and Governmental Affairs 

reported that federal agencies involved in providing medical assistance did 

not have adequate resources or the right medical capabilities to fully meet

the medical needs arising from Katrina, such as meeting the needs of large 

evacuee populations, and were forced to use improvised and unproven 

techniques to meet those needs.27 Further, the committee reported that the 

federal government’s medical response suffered from a lack of planning, 

coordination, and cooperation. 

Federal Reports on Health 

Care Facility Evacuation 

Due to Hurricane Katrina 

 23The CMS State Operations Manual includes interpretive guidelines and survey procedures 

for state agencies that assess compliance with CMS regulations. 

24Assistant to the President for Homeland Security and Counterterrorism, The Federal

Response to Hurricane Katrina: Lessons Learned (Feb. 23, 2006). 

25U.S. House of Representatives, February 2006. 

26Department of Homeland Security, Office of Inspector General, A Performance Review of

FEMA’s Disaster Management Activities in Response to Hurricane Katrina, OIG-06-32 

(Washington, D.C.: Mar. 31, 2006). 

27Committee on Homeland Security and Governmental Affairs, May 2006. 

Page 10 GAO-06-826 Evacuation of Hospitals and Nursing Homes
Hospital and nursing home administrators faced several challenges related 

to evacuation during recent hurricanes, including deciding whether to 

evacuate or stay in their facilities and “shelter in place”, obtaining 

transportation necessary for evacuations, and maintaining communication 

outside of their facilities. Administrators said they generally prefer to 

shelter in place, and when doing so must have the resources needed to 

provide care during a hurricane, and maintain self-sufficiency immediately 

after a hurricane to continue to care for patients until help can arrive. 

When evacuations were needed, facility administrators said that they had 

problems with transportation. Facilities had contracts with transportation 

companies, but competition for the same pool of vehicles created supply 

shortages. In addition, communication was impaired by damage to local 

infrastructure as a result of the hurricanes. For example, a nursing home 

in Florida was unable to communicate with local emergency managers. 

Hospital and nursing home administrators told us that they faced 

challenges in deciding whether to evacuate, including ensuring that they

had sufficient resources to provide care or other services during the 

disaster and then in its aftermath until assistance could arrive.

Administrators told us that they evacuate only as a last resort and that 

facilities’ emergency plans are designed primarily to shelter in place. Some 

hospitals provided a safe haven for devastated communities after a 

hurricane. In addition, some hospitals saw a surge in the number of people 

seeking care as a result of injuries sustained during the hurricane. For 

example, clinicians at a 153-bed hospital in Mississippi treated 

approximately 500 patients per day in the days after Hurricane Katrina, a 

substantial increase from their normal workload of about 130 patients per 

day. This hospital’s administrators told us that they felt obligated to 

remain open to serve the community’s needs. In addition, facility 

administrators and county representatives that we interviewed agreed that 

sheltering in place is generally safer than evacuating vulnerable hospital 

patients and nursing home residents. Although state and local

governments can issue mandatory evacuation orders for certain areas, 

health care facilities may be exempt from these orders, as they were in a 

Mississippi county for Hurricane Katrina. When preparing to shelter in 

place, hospital administrators told us that they discharge patients when 

possible and stop performing elective surgeries to reduce the number of 

patients in the hospital.

In anticipation of an inability to replenish resources during a hurricane, 

hospital and nursing home administrators take steps before hurricanes to 

ensure that the facilities have the resources needed to shelter in place and

Facility 

Administrators Faced 

Several Challenges 

Related to 

Evacuation, Including 

Deciding Whether to 

Evacuate, Securing 

Transportation, and 

Maintaining 

Communication 

Facility Administrators 

Faced Challenges in 

Deciding Whether to 

Evacuate or Shelter in 

Place 

Page 11 GAO-06-826 Evacuation of Hospitals and Nursing Homes
adequately care for patients and residents, including sufficient supplies, 

food, water, and power. For example, a nursing home administrator in 

Florida told us that the facility prepared for Hurricane Charley by 

obtaining 10 days of food and water for its 120 residents plus additional 

Meals, Ready-to-Eat28 to feed 500 people for up to 4 days, including staff 

and their families. Administrators from a hospital told us that they call 

their vendors 72 hours before a hurricane to order bulk supplies of milk, 

bread, and paper goods. Administrators from a Mississippi hospital noted 

that they prepare for hurricanes by ensuring that the facility has 3-4 days 

of clean linens and 5-6 days of medical supplies. Administrators must also 

make sure they have sufficient backup electrical power because life 

support systems require electricity to operate. One hospital administrator 

acquired an additional generator to extend the hospital’s capacity to 

supply backup power to 10 days. In addition, many of the administrators 

we interviewed noted that they maintain large fuel tanks to power the 

generators. For example, one hospital maintained a 20,000 gallon tank, 

which holds enough fuel to run the facility’s generators for 1 week. Some 

administrators told us that they also had difficulty obtaining sufficient fuel

after the hurricanes. 

In addition to obtaining tangible supplies, administrators face the 

challenge of ensuring that facilities have the staff needed to provide 

adequate patient care during and after a hurricane. Hospital administrators 

noted the challenges involved with having sufficient numbers of clinical 

staff, such as doctors, available during hurricanes. Some facility 

administrators we interviewed identified “storm teams” of staff that were 

required to report to the facility before a hurricane and remain on site 

during the event. One hospital required the “storm team” to be prepared to

stay at the facility for 3-4 days. Staff members were required to bring 

clothes, bedding, snacks, and other personal items. In some cases, 

facilities also allowed these staff members to bring their families and pets. 

One hospital administrator in Mississippi noted that the severity and 

destruction caused by Hurricane Katrina prevented the relief staff from 

taking over and the “storm team” remained at the facility for 14 days. 

Another hospital administrator in Florida noted that after Hurricane 

Charley, relief staff did not report for work. 

Hospital and nursing home administrators we interviewed reported that 

their facilities needed to be self-sufficient for a period of time immediately 

 28Meals, Ready-to-Eat are precooked meal kits developed for soldiers in combat conditions. 

Page 12 GAO-06-826 Evacuation of Hospitals and Nursing Homes
after a hurricane because new supplies may not arrive for several days. 

For example, a representative of a Florida nursing home association said 

that facilities need at least 10 days of supplies to effectively shelter in 

place until help can arrive. The need to be self-sufficient is especially

important when disasters affect entire communities and delay response 

efforts, as demonstrated during hurricanes Charley and Katrina. Facilities 

that were part of networks were able to call on their corporate offices or 

sister facilities outside of the affected area to replenish needed supplies 

after a hurricane. For example, one administrator said that the company 

that owns his hospital has a division that tracks each facility’s

preparedness resources, and the company’s supply warehouse has 

“disaster packs” of necessary supplies ready to be deployed in case of 

emergency. Additionally, the company has large contracts in place so that

it can quickly obtain resources like fuel, generators, and staff. 

Facility administrators noted that they were not always able to obtain 

appropriate vehicles to accommodate their facilities’ patient needs. While 

some people can be moved using buses, some may require wheelchairaccessible vehicles, and others may need to be transported by ambulance. 

For example, one nursing home administrator noted that the facility 

contracted with a bus company, but stated that transportation remained a 

challenge because most of the facility’s residents used electric wheelchairs 

and needed vehicles with power lifts, which were not available. In 

addition, facilities also needed trucks to move staff and supplies to care 

for the patients. For example, one Florida nursing home administrator 

noted that the facility had arrangements with a trucking company to load 

and transport patient medical records, medications, laundry supplies, 

food, and water. Another nursing home administrator in Mississippi said 

that he rented a truck to move mattresses and other supplies for his 

residents. 

Having a contract with a transportation company or relying on the local 

government did not guarantee availability of transportation resources 

during a hurricane. Although facility administrators reported having 

contracts with transportation companies, competition for the same pool of 

vehicles created supply shortages. Hospital and nursing home 

administrators in several communities told us that their transportation 

companies also had contracts with other facilities in the community to 

provide services, a situation that may be sufficient for small evacuations 

but did not work when there were multiple facilities from the same area 

that needed to evacuate. In addition to contracting with multiple facilities, 

some companies’ vehicles were unavailable due to advance notice 

Facility Administrators 

Had Problems Related to 

Transportation for Patient 

Evacuations 

Page 13 GAO-06-826 Evacuation of Hospitals and Nursing Homes
requirements, and others may have had vehicles that were badly damaged

by the hurricane. For example, one nursing home administrator said that 

the bus company his facility contracted with required 24-hours notice 

before a bus could be chartered, and that providing this notice was 

difficult in a disaster situation. Some facilities relied upon local 

government resources to provide assistance with evacuations, but when 

an entire community was severely affected, local ambulances were 

damaged or in short supply and therefore unavailable. For example, one 

Florida hospital administrator had arranged for transportation through the 

local emergency operations center (EOC), but the hurricane destroyed the 

EOC. In contrast, when local officials in Mississippi faced a shortage of 

ambulances immediately after Hurricane Katrina, they called upon a 

national ambulance company, with which they had a contract, to provide 

additional resources from Texas and Alabama. Officials noted that state 

resources were not available after the storm and contracting with an 

ambulance company with national resources was beneficial. 

Hurricanes Charley and Katrina caused significant damage to the 

infrastructure of the surrounding communities, and left some hospital and 

nursing home administrators unable to communicate outside of their 

facilities. Several administrators that we interviewed reported that landbased telephone lines were not functional and cellular telephone reception

was sporadic. Some administrators reported that cell phones based in 

other areas were more reliable than local cell phones. Since the 2004 

hurricane season, some facilities in Florida have purchased satellite 

phones. For example, one nursing home administrator who faced 

communications difficulties after Hurricane Charley has since purchased 

satellite phones. However, during Hurricane Katrina, some Mississippi 

hospital administrators told us that their satellite phones did not function. 

Because no single communications technology is universally reliable, 

some facility administrators told us that they plan to diversify their 

communication capabilities by utilizing multiple forms of communication. 

Communication problems also affected county officials. Local EOC 

officials in both Mississippi and Florida reported being unable to 

communicate with state officials or local health care facilities. Because of 

communication problems at the local EOC, one nursing home 

administrator in Florida asked a staff member to drive to the EOC to 

communicate in person. In Mississippi, emergency managers relied on 

Facility Administrators 

Faced Communication 

Challenges Due to Damage 

to Local Infrastructure 

Caused by Hurricanes 

Page 14 GAO-06-826 Evacuation of Hospitals and Nursing Homes
handheld radios and personal contact to communicate immediately after 

the hurricane. We have previously reported on communication difficulties

during a public health emergency.29

NDMS has two limitations in its design that constrain its assistance to 

state and local governments with patient evacuation. First, NDMS is not 

designed to move patients or residents out of hospitals or nursing homes 

to mobilization centers. Second, NDMS was not designed nor is it 

currently configured for people who do not need hospital care, including

nursing home residents. 

The first limitation of NDMS is that it is designed to move patients from a 

mobilization center, such as an airport, to other locations where they can 

receive necessary medical care, but it is not designed to move patients or 

residents out of hospitals or nursing homes to mobilization centers. NDMS 

officials told us that transportation from a health care facility to an NDMS 

mobilization center is the responsibility of local and state governments. 

Moreover, NDMS does not include helicopters, ambulances, or other 

short-distance vehicles necessary to move patients out of hospitals or 

nursing homes to mobilization centers. NDMS officials stated that NDMS 

transportation assets typically are large DOD airplanes designed to travel 

long distances, which can take approximately 24 hours or more to arrange. 

In addition, NDMS officials told us that to obtain ambulance or helicopter 

service, they would contract with private providers near a disaster site, 

which could lead to competition between the federal government and 

state and local authorities for the same pool of limited resources.30

Although NDMS evacuation efforts begin at mobilization centers, federal 

officials told us that no federal program is designed to move patients or 

residents out of hospitals or nursing homes to mobilization centers. NDMS 

and other documents that we reviewed also do not identify other federal 

programs that might assist in performing this function. We reviewed the 

NRP, the September 2005 draft Catastrophic Incident Supplement to the 

NRP, and NDMS documents. They do not indicate how the federal 

NDMS Has Two 

Limitations That 

Constrain Its 

Assistance to State 

and Local 

Governments with 

Patient Evacuation 

and Which Are Not 

Addressed Elsewhere 

in the NRP 

 29See, for example, GAO, Bioterrorism: Information Technology Strategy Could

Strengthen Federal Agencies’ Abilities to Respond to Public Health Emergencies, 

GAO-03-139 (Washington, D.C.: May 30, 2003). 

30For example, a DOT official told us that the federal government and the state of Texas 

competed to obtain vehicles due to Hurricane Rita. 

Page 15 GAO-06-826 Evacuation of Hospitals and Nursing Homes
government is to assist state and local authorities in moving hospital 

patients and nursing home residents from their facilities. In particular, the 

September 2005 draft Catastrophic Incident Supplement to the NRP, 

which is intended to be used with the Catastrophic Incident Annex when a 

catastrophic incident almost immediately overwhelms the capabilities of 

state and local governments, states that collecting and transporting 

patients from health care facilities to mobilization centers is the 

responsibility of state and local authorities. The draft supplement does not 

describe what, if any, role the federal government may play in

coordinating with state and local authorities for this kind of 

transportation. 

Despite this limitation of NDMS, some federal assistance was provided to 

move people out of health care facilities during Hurricane Katrina. Coast 

Guard officials told us that they evacuated about 9,400 people from 

hospitals and nursing homes as part of their search and rescue operations. 

NDMS officials reported that private, local, state, and federal resources 

transported hospital patients and nursing home residents to mobilization 

points, but there was a lack of coordination. For example, a report 

prepared by NDMS officials after Hurricane Katrina noted that, initially,

transportation resources from the Coast Guard and DOD were not 

coordinated.31

The second limitation is that NDMS was not designed nor is it currently 

configured for people who do not need hospital care, including nursing 

home residents. As stated in the memorandum of agreement among the 

NDMS federal partners, the patient evacuation function of NDMS is 

intended to move patients so that they can receive medical care in NDMS 

hospitals—typically nonfederal hospitals that have agreements with 

NDMS. NDMS officials told us that they do not have agreements with 

nursing homes or other types of health care providers. However, because 

of the immediate demands posed by Hurricane Katrina, federal officials 

told us that NDMS had to move people who did not need hospital care, 

including nursing home residents and members of the general public who 

arrived at NDMS mobilization centers. NDMS flights evacuated people 

with various needs from mobilization centers to NDMS patient reception 

areas where officials assessed their health needs and arranged for them to 

 31NDMS, National Disaster Medical System (NDMS) After Action Review (AAR) Report 

on Patient Movement and Definitive Care Operations in Support of Hurricanes Katrina

and Rita (Jan. 12, 2006). 

Page 16 GAO-06-826 Evacuation of Hospitals and Nursing Homes
receive additional medical care through the definitive care portion of 

NDMS. NDMS reception areas had to make special arrangements for 

people in need of nursing home care, because NDMS lacked preexisting 

agreements with nursing homes equipped to handle people with 

nonhospital health care needs.32 In a report prepared by NDMS after the 

hurricane, federal officials noted that NDMS was not optimally prepared to

manage the nursing home requirements of evacuees who did not require 

hospitalization.33 The movement of nursing home residents during 

evacuations is not addressed elsewhere in the NRP. 

At the federal level, CMS has requirements related to hospital and nursing 

home disaster and evacuation planning as a condition of participation in 

the Medicare and Medicaid programs. For hospitals, a CMS requirement 

states that the overall hospital environment must be maintained to assure 

the safety and well-being of patients.34 According to CMS guidelines for 

interpreting this regulation, hospitals must develop and maintain 

comprehensive emergency plans, and when developing plans, should 

consider the transfer of patients to other health care settings or hospitals if 

necessary. For nursing homes, a CMS regulation states that facilities must 

have plans to meet all potential emergencies and disasters, although the 

interpretative guidelines do not specifically mention transfer of residents.35

CMS officials told us that, based on experiences during Hurricane Katrina, 

they have established a work group within CMS to review hospital and 

nursing home requirements and other provider standards, policies, and 

guidance related to emergency preparedness, including issues related to 

evacuations. The officials told us that they expect the work group to make 

initial recommendations for improvement in 2006. (See app. II for CMS 

regulations and interpretive guidelines related to evacuation planning and 

emergency preparedness.) 

In addition to CMS requirements, JCAHO, AOA, and states can establish 

additional emergency management requirements for health care facilities. 

For hospitals that it accredits, JCAHO requires that emergency plans 

include provisions for evacuating the entire building and transporting 

Federal Requirements 

for Hospitals and 

Nursing Homes 

Include Provisions for 

Having Disaster Plans 

and Transferring 

Patients Out of 

Hospitals 

 32For related information, see GAO-06-443R. 

33NDMS 2006. 

3442 C.F.R. § 482.41(a) (2005). 

3542 C.F.R. § 483.75(m) (2005). 

Page 17 GAO-06-826 Evacuation of Hospitals and Nursing Homes
patients, supplies, staff, and equipment to alternate care sites if 

necessary.36 AOA requires that emergency plans for hospitals that it 

accredits include provisions for transferring patients and supplies to other 

settings for health care if necessary. (See app. III for a list of JCAHO and 

AOA requirements related to evacuation planning and emergency 

preparedness.) States can also establish additional requirements for 

facility evacuation planning that relate to transportation. For example, 

Florida requires hospitals and nursing homes to have comprehensive 

emergency management plans that document transportation arrangements 

to be used to evacuate residents.37 Mississippi requires nursing homes to 

maintain written transfer agreements with other facilities or alternative 

shelters in the event of a disaster.38 The state also requires hospitals to 

have written disaster preparedness plans that include relocation 

arrangements, including transportation arrangements, in the event of an

evacuation.39

Federal requirements for hospitals and nursing homes include provisions 

that the facilities plan for disasters and emergencies. However, when 

hurricanes Charley and Katrina hit the Gulf Coast area, they created 

significant challenges for health care facility administrators that faced 

evacuation, including deciding whether to evacuate, securing

transportation, and maintaining communications outside of their facilities. 

In particular, securing transportation was challenging because when 

multiple health care facilities within a community decided to evacuate,

they had difficulty obtaining the number and type of vehicles needed and 

competed with each other for a limited supply of vehicles. 

A federal role related to evacuation is described in various documents, 

including the NDMS memorandum of agreement, the NRP, and its draft 

Catastrophic Incident Supplement. However, the challenges faced by

hospitals and nursing homes during hurricanes Charley and Katrina also 

Conclusions 

 36However, JCAHO officials stated that, in a disaster that affects the entire community, the

requirements would not prevent multiple facilities from competing for the same 

transportation resources or alternate care sites. 

37Fla. Stat. § 395.1055(1)(c) (2005); Fla. Admin. Code Ann. r. 59A-4.126 (2005); and 

Emergency Mgmt. Planning Criteria for Nursing Home Facilities, ACHA 3110-6006, March 

1994. 

3812-000-045 Miss. Code R. § 405.1 (Weil 2006). 

3912-000-040 Miss. Code R. § 1401.5 (Weil 2006). 

Page 18 GAO-06-826 Evacuation of Hospitals and Nursing Homes
revealed two limitations in the federal government’s support to health care 

facilities that have to evacuate—the lack of assistance to states and 

localities to move people out of health care facilities to a mobilization 

point for federal transportation support and the lack of attention to 

nursing home residents needing evacuation. In terms of the first limitation, 

we found that the reliance in the NDMS design on local and state 

resources to move people directly out of facilities is inadequate when 

multiple facilities in the community have to evacuate simultaneously and 

compete for too few vehicles. In addition, DHS’s draft Catastrophic 

Incident Supplement to the NRP, which is intended to offer guidance for a 

situation in which state and local resources are overwhelmed, also would 

leave responsibility for moving people out of health care facilities on state 

and local authorities. It does not describe the role the federal government

may play in coordinating with state and local authorities during hospital 

and nursing home evacuations. In terms of the second limitation, we noted 

that the evacuation of nursing home residents was not considered when 

NDMS was originally designed in 1984—nor is it currently addressed 

elsewhere in the NRP—but the experiences of these recent hurricanes also

showed that the needs of this population when evacuations are required 

have been overlooked in the federal plans. 

DHS is the lead agency responsible for issuance and maintenance of the 

NRP, development of the draft Catastrophic Incident Supplement, and 

activation of NDMS. Until it addresses these limitations—within NDMS, 

the NRP, or through other mechanisms—vulnerabilities in the evacuation 

of hospitals and nursing homes will continue, and the federal

government’s response will not be as effective as possible. 

To address limitations in how the federal government provides assistance 

with the evacuation of health care facilities, we recommend that the 

Secretary of Homeland Security take the following two actions: 

Recommendations for 

Executive Action 

• Clearly delineate how the federal government will assist state and local 

governments with the movement of patients and residents out of hospitals 

and nursing homes to a mobilization center where NDMS transportation 

begins. 

• In consultation with the other NDMS federal partners—the Secretaries of

Defense, Health and Human Services, and Veterans Affairs—clearly 

delineate how to address the needs of nursing home residents during 

evacuations, including the arrangements necessary to relocate these 

residents. 

Page 19 GAO-06-826 Evacuation of Hospitals and Nursing Homes
We received written comments on a draft of this report from DHS, DOD, 

HHS, and VA. 

DHS stated that it will take our recommendations under advisement as it 

reviews the National Response Plan. According to DHS, all of the NDMS 

federal partners are currently reviewing the NDMS memorandum of 

agreement with a view towards working with state and local partners to 

alter, delineate, and otherwise clarify roles and responsibilities as 

appropriate. DHS confirmed that the primary responsibility for 

evacuations remains with state and local governments and that the federal 

government becomes involved only when the capabilities of the state and 

local governments are overwhelmed. However, as stated in the draft 

report, neither NDMS documents, the NRP, nor the draft Catastrophic 

Incident Supplement to the NRP—to be used in cases when the 

capabilities of state and local governments are almost immediately 

overwhelmed—describe the federal role in coordinating with state and 

local authorities during hospital and nursing home evacuations. We also 

noted that reliance on state and local resources was inadequate when 

multiple facilities in a community had to evacuate simultaneously. DHS’s 

written comments are reprinted in appendix IV. 

DOD disagreed with our conclusions concerning NDMS’s two limitations. 

First, DOD stated that our report implies that the provision of shortdistance transportation is a federal responsibility, but DOD maintains that

it is a state and local responsibility. However, during a catastrophic 

incident, the capabilities of state and local governments may almost 

immediately become overwhelmed. As we stated above in our response to 

DHS’s comments, the federal role in these situations has not been 

described. Second, DOD stated that our conclusion regarding the needs of 

nursing home residents was technically correct, but that we failed to 

describe the successful evacuation of nursing home residents during 

Hurricane Rita. Our draft report did describe NDMS’s evacuation of 

people, including nursing home residents and other people who did not 

need hospital care, during recent hurricanes due to the immediate 

demands posed by the storms. However, we also noted that the NDMS 

after-action report on hurricanes Katrina and Rita states that NDMS was 

not optimally prepared to manage the nursing home requirements of 

evacuees who did not require hospitalization. For this reason, we believe

that explicit consideration of the needs of nursing home residents is 

warranted. DOD’s written comments are reprinted in appendix V. 

HHS concurred with our recommendations and made two general 

comments. First, HHS noted that we should address the role of DOT in the 

Agency Comments 

and Our Evaluation 

Page 20 GAO-06-826 Evacuation of Hospitals and Nursing Homes
NRP to provide transportation support for domestic emergencies. Under 

ESF #8, DOT can assist with identifying and arranging for all types of 

transportation. However, as stated in the draft report, the NRP does not 

indicate how DOT or other federal agencies are to assist state and local 

authorities in moving hospital patients and nursing home residents from 

their facilities. Second, HHS commented that the report does not describe 

why NDMS was designed to focus on hospital evacuation, but HHS did not 

provide any additional information about NDMS’s origins. Although the 

draft report included available information on the origins of NDMS, our 

assessment focused on the program’s current status. HHS’s written 

comments are reprinted in appendix VI. 

VA agreed with our conclusions and recommendations and stated that it 

would continue to address issues raised in the draft report. VA’s written 

comments are reprinted in appendix VII. 

DHS and HHS also provided technical comments. In addition, DOT 

provided technical comments via email. We incorporated these comments 

where appropriate. 

We are sending copies of this report to the Secretaries of DOD, HHS, DHS, 

DOT, VA, and other interested parties. We will also make copies available 

to others on request. In addition, the report will be available at no charge 

on GAO’s Web site at http://www.gao.gov. 

If you or your staff have any questions about this report, please contact me 

at (202) 512-7101 or bascettac@gao.gov. Contact points for our Offices of 

Congressional Relations and Public Affairs may be found on the last page 

of this report. GAO staff who made major contributions to this report are 

listed in appendix VIII. 

Cynthia A. Bascetta 

Director, Health Care 

Page 21 GAO-06-826 Evacuation of Hospitals and Nursing Homes
List of Committees 

The Honorable Charles E. Grassley 

Chairman 

The Honorable Max Baucus 

Ranking Minority Member 

Committee on Finance 

United States Senate 

The Honorable Michael B. Enzi 

Chairman 

The Honorable Edward M. Kennedy 

Ranking Minority Member 

Committee on Health, Education, 

Labor, and Pensions 

United States Senate 

The Honorable Susan M. Collins 

Chairman 

Committee on Homeland Security and 

Governmental Affairs 

United States Senate 

The Honorable Daniel K. Akaka 

Ranking Minority Member 

Committee on Veterans’ Affairs 

United States Senate 

The Honorable Gordon H. Smith 

Chairman 

The Honorable Herb Kohl 

Ranking Minority Member 

Special Committee on Aging 

United States Senate 

The Honorable Ike Skelton 

Ranking Minority Member 

Committee on Armed Services 

House of Representatives 

Page 22 GAO-06-826 Evacuation of Hospitals and Nursing Homes
The Honorable Joe Barton 

Chairman 

The Honorable John D. Dingell 

Ranking Minority Member 

Committee on Energy and Commerce 

House of Representatives 

The Honorable Tom Davis 

Chairman 

The Honorable Henry A. Waxman 

Ranking Minority Member 

Committee on Government Reform 

House of Representatives 

The Honorable Bennie G. Thompson

Ranking Minority Member 

Committee on Homeland Security 

House of Representatives 

The Honorable Steve Buyer 

Chairman 

The Honorable Lane Evans 

Ranking Minority Member 

Committee on Veterans’ Affairs 

House of Representatives 

The Honorable William M. Thomas 

Chairman 

The Honorable Charles B. Rangel 

Ranking Minority Member 

Committee on Ways and Means 

House of Representatives 

Page 23 GAO-06-826 Evacuation of Hospitals and Nursing Homes
Appendix I: Scope and Methodology Appendix I: Scope and Methodology 

To examine the challenges hospital and nursing home administrators 

faced related to recent hurricanes, we conducted case studies in two 

states—Florida and Mississippi. We selected these states based on their 

experience with previous disasters. During 2004, the state of Florida was 

hit by four hurricanes—Charley, Frances, Ivan, and Jeanne. Hurricane 

Charley was the strongest of these four, and the strongest hurricane to hit 

the United States since Hurricane Andrew hit southern Florida in 1992.1

 In 

2005, Mississippi received heavy storm damage from Hurricane Katrina 

caused by wind and an extremely high storm surge. 

In Florida, to understand the role of the state and local governments in 

evacuating hospitals and nursing homes, we interviewed and obtained 

documents from state and county officials. At the state level, we 

interviewed officials from the Florida Department of Health’s Office of 

Emergency Operations. We reviewed the Florida Comprehensive 

Emergency Management Plan, as well as Florida’s after-action report for 

the 2004 Hurricane season. At the local level, we selected two counties 

affected by Hurricane Charley—Charlotte and Volusia counties. Charlotte 

County, the entry point for the hurricane, is located on the Gulf Coast of 

Florida. Volusia County, the exit point for the hurricane, is located on the 

Atlantic Coast of the state. Within each county, we interviewed emergency 

management officials and reviewed county emergency management plans. 

To obtain information on the experiences of individual health care 

facilities in Florida, we identified hospitals and nursing homes within each 

of the selected counties, interviewed facility administrators, and reviewed 

documents. To select facilities, we asked emergency management officials 

in each county to provide contact information for hospitals and nursing 

homes that either evacuated or sheltered in place due to Hurricane 

Charley. In cases where the representatives identified by county officials 

were unavailable, we selected alternate health care facilities based on 

their proximity to the ocean. For each facility, we obtained and reviewed 

applicable emergency plans, hurricane plans, and/or evacuation plans. In

total, we interviewed administrators from two hospitals and two nursing 

homes in Charlotte County and one hospital and two nursing homes in 

Volusia County. In addition to facility administrators, we interviewed 

officials from the Florida Hospital Association, the Florida Association of 

Homes for the Aging, and the Florida Health Care Association. 

 1

Hurricane Charley was a category 4 storm on the Saffir-Simpson hurricane rating scale. 

(Category 5 is the strongest possible category on the scale.) 

Page 24 GAO-06-826 Evacuation of Hospitals and Nursing Homes
Appendix I: Scope and Methodology 

In Mississippi, to understand the role of the state and local governments in 

evacuating hospitals and nursing homes, we interviewed and obtained 

documents from state and county officials. At the state level, we 

interviewed officials from the Mississippi Emergency Management Agency 

and Department of Health, and reviewed documents including the 

Mississippi Comprehensive Emergency Management Plan. At the local

level, we selected the two coastal counties that were hit most directly by

Hurricane Katrina—Hancock and Harrison counties. Hancock County, 

which includes the cities of Waveland and Bay St. Louis, was directly in 

the path of the storm and sustained extensive damage. Harrison County, 

which is adjacent to Hancock County and includes the cities of Gulfport 

and Biloxi, sustained extensive damage and has the area’s largest 

population. In each county, we interviewed emergency management 

officials. We also reviewed emergency management plans from Hancock 

and Harrison counties. 

To obtain information on the experience of individual health care facilities 

in Mississippi, we identified hospitals, nursing homes, and assisted living 

facilities within each of the selected counties; interviewed facility 

administrators; and reviewed documents provided. To locate health care 

facilities, we relied on a list of hospitals, nursing homes, and assisted living 

facilities in Hancock and Harrison counties from a June 2005 Mississippi 

Department of Health report on hospitals2

 and a September 2005 

Mississippi Department of Health report on institutions for the aged or 

infirm.3

 We also identified facilities in Harrison County that were operated 

by the Department of Veterans Affairs (VA). We excluded nursing homes 

with fewer than 20 licensed beds. From this list, we selected facilities 

based on ownership type, vulnerability and proximity to the ocean, and 

size. For each facility, we obtained and reviewed emergency plans, 

hurricane plans, and/or evacuation plans. In total, we interviewed officials 

from one hospital and one nursing home in Hancock County and four 

hospitals and two assisted living facilities in Harrison County. We also 

interviewed representatives from the Gulf States Association of Homes 

and Services for the Aging. 

 2

Mississippi Department of Health, Division of Health Facilities Licensure and Certification, 

2004 Report on Hospitals (Jackson, Miss.: June 2005). 

3

Mississippi Department of Health, Bureau of Health Facilities Licensure and Certification, 

2004 Report on Institutions for the Aged or Infirm (Jackson, Miss.: September 2005). 

Page 25 GAO-06-826 Evacuation of Hospitals and Nursing Homes
Appendix I: Scope and Methodology 

To examine the extent to which limitations exist in the design of the 

National Disaster Medical System (NDMS) or other federal programs to 

assist state and local governments with patient evacuations, we reviewed 

federal documents such as the National Response Plan, including 

Emergency Support Function #8—Public Health and Medical Services—

and the Catastrophic Incident Annex. We also obtained and reviewed a 

September 2005 draft of the Catastrophic Incident Supplement to the NRP. 

We interviewed emergency preparedness officials from the Department of 

Defense, the Department of Health and Human Services, the Department 

of Homeland Security, the Department of Transportation, and the VA. To

obtain additional information on NDMS, we reviewed program documents, 

including the memorandum of agreement that governs NDMS and an afteraction report on the use of NDMS due to Hurricane Katrina. 

To examine the federal requirements for hospital and nursing home 

disaster and evacuation planning, we reviewed documents that identify the 

federal requirements and national standards related to emergency 

management, disaster preparedness, and patient evacuation. We reviewed

documents provided by the Centers for Medicare & Medicaid Services 

(CMS) and by accrediting organizations that assess compliance with CMS 

requirements—the Joint Commission on Accreditation of Healthcare 

Organizations and the American Osteopathic Association. We also 

interviewed officials from these organizations concerning the 

requirements and enforcement mechanisms, as well as officials from the 

American Hospital Association, Federation of American Hospitals, and the 

American Health Care Association. In addition, we interviewed and 

obtained documents from the Florida Agency for Health Care 

Administration officials responsible for the licensing and certification of 

health care facilities as well as officials from the Mississippi Department 

of Health. We performed our work from October 2005 through July 2006 in

accordance with generally accepted government auditing standards. 

Page 26 GAO-06-826 Evacuation of Hospitals and Nursing Homes
Appendix II: CMS Regulations and 

Interpretive Guidelines Related to Hospital 

and Nursing Home Disaster and Evacuation 

The Centers for Medicare & Medicaid Services (CMS) establishes federal

regulations that hospitals and nursing homes must meet to participate in

the Medicare and Medicaid programs. CMS’s interpretive guidelines 

contain authoritative interpretations and clarifications of statutory and 

regulatory requirements and are to be used to make determinations about

compliance with requirements. The tables below include regulations for 

hospitals and nursing homes that relate to disaster and evacuation 

planning. Table 1 includes CMS regulations and interpretive guidelines for 

hospitals. 

Table 1: CMS Regulation and Interpretive Guidelines for Hospitals 

RegulationaInterpretive guidelinesb

42 C.F.R. § 482.41(a) 

Buildings 

The condition of the physical plant and the 

overall hospital environment must be 

developed and maintained in such a manner

that the safety and well being of patients are 

assured. 

The hospital must ensure that the condition of the physical plant and overall hospital

environment is developed and maintained in a manner to ensure the safety and well 

being of patients. This includes ensuring that routine and preventive maintenance and 

testing activities are performed as necessary, in accordance with Federal and State 

laws, regulations, and guidelines and manufacturer’s recommendations, by establishing

maintenance schedules and conducting ongoing maintenance inspections to identify 

areas or equipment in need of repair. The routine and preventive maintenance and 

testing activities should be incorporated into the hospital’s QAPIb

 plan. 

Assuring the safety and well being of patients would include developing and 

implementing appropriate emergency preparedness plans and capabilities. The hospital 

must develop and implement a comprehensive plan to ensure that the safety and well

being of patients are assured during emergency situations. The hospital must 

coordinate with Federal, State, and local emergency preparedness and health 

authorities to identify likely risks for their area (e.g., natural disasters, bioterrorism 

threats, disruption of utilities such as water, sewer, electrical communications, fuel; 

nuclear accidents, industrial accidents, and other likely mass casualties, etc.) and to 

develop responses that will assure the safety and well being of patients. The following 

issues should be considered when developing the comprehensive emergency plan(s): 

• The differing needs of each location where the certified hospital operates; 

• The special needs of patient populations treated at the hospital (e.g., patients with 

psychiatric diagnosis, patients on special diets, newborns, etc.); 

• Security of patients and walk-in patients; 

• Security of supplies from misappropriation; 

• Pharmaceuticals, food, other supplies and equipment that may be needed during 

emergency/disaster situations; 

• Communication to external entities if telephones and computers are not operating or 

become overloaded (e.g., ham radio operators, community officials, other healthcare 

facilities if transfer of patients is necessary, etc.); 

• Communication among staff within the hospital itself; 

• Qualifications and training needed by personnel, including healthcare staff, security 

staff, and maintenance staff, to implement and carry out emergency procedures; 

• Identification, availability and notification of personnel that are needed to implement 

and carry out the hospital’s emergency plans; 

Appendix II: CMS Regulations and 

Interpretive Guidelines Related to Hospital 

and Nursing Home Disaster and Evacuation 

Page 27 GAO-06-826 Evacuation of Hospitals and Nursing Homes
Appendix II: CMS Regulations and 

Interpretive Guidelines Related to Hospital 

and Nursing Home Disaster and Evacuation 

RegulationaInterpretive guidelinesb

• Identification of community resources, including lines of communication and names 

and contact information for community emergency preparedness coordinators and 

responders; 

• Provisions if gas, water, electricity supply is shut off to the community; 

• Transfer or discharge of patients to home, other healthcare settings, or other 

hospitals; 

• Transfer of patients with hospital equipment to another hospital or healthcare setting; 

and 

• Methods to evaluate repairs needed and to secure various likely materials and 

supplies to effectuate repairs. 

Source: CMS State Operations Manual. 

a

GAO analyzed regulations and interpretive guidelines for hospitals that specifically pertain to 

evacuation planning and emergency preparedness. For a full list of CMS regulations and interpretive 

guidelines for hospitals, see the CMS State Operations Manual, Appendix A – Survey Protocol, 

Regulations and Interpretive Guidelines for Hospitals. 

b

According to CMS, hospitals use a quality assessment performance improvement (QAPI) plan to 

systematically examine quality and implement specific improvement projects on an ongoing basis. 

Page 28 GAO-06-826 Evacuation of Hospitals and Nursing Homes
Appendix II: CMS Regulations and 

Interpretive Guidelines Related to Hospital 

and Nursing Home Disaster and Evacuation 

Table 2 includes CMS regulations and interpretive guidelines for nursing 

homes. CMS surveyors conduct health care facility surveys to evaluate the 

manner and degree to which the providers satisfy various CMS 

requirements or standards. Long-term care facilities include nursing 

homes. 

Table 2: CMS Guidance to Surveyors for Long Term Care Facilities 

RegulationaInterpretive guidelinesb

42 C.F.R. § 483.70 

Physical Environment 

The facility must be designed, constructed, 

equipped, and maintained to protect the health 

and safety of residents, personnel and the public. 

42 C.F.R. § 483.75 

Administration

A facility must be administered in a manner that 

enables it to use its resources effectively and 

efficiently to attain or maintain the highest 

practicable physical, mental, and psychosocial 

well-being of each resident. 

42 C.F.R. § 483.75(m) 

Disaster and Emergency Preparedness 

1. The facility must have detailed written plans 

and procedures to meet all potential 

emergencies and disasters, such as fire, 

severe weather, and missing residents. 

2. The facility 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. 

The facility should tailor its disaster plan to its geographic location and the types 

of residents it serves. “Periodic review” is a judgment made by the facility based

on its unique circumstances[.] [C]hanges in physical plan or changes external to 

the facility can cause a review of the disaster review plan[.] 

The purpose of a “staff drill” is to test the efficiency, knowledge, and response of 

institutional personnel in the event of an emergency. Unannounced staff drills are 

directed at the responsiveness of staff, and care should be taken not to disturb or 

excite residents. 

Source: CMS State Operations Manual. 

a

GAO analyzed regulations and interpretive guidelines for nursing homes that specifically pertain to 

evacuation planning and emergency preparedness. For a full list of CMS regulations and interpretive 

guidelines for nursing homes, see the CMS State Operations Manual, Appendix PP – Guidance to 

Surveyors for Long Term Care Facilities.

b

Some regulations do not have interpretive guidelines. 

Page 29 GAO-06-826 Evacuation of Hospitals and Nursing Homes
Appendix III: JCAHO and AOA Requirements 

for Hospital Evacuation Planning and Appendix III: JCAHO and AOA Requirements Emergency Preparedness 

for Hospital Evacuation Planning and 

Emergency Preparedness 

Hospitals that are accredited by the Joint Commission on Accreditation of 

Healthcare Organizations (JCAHO) or the American Osteopathic 

Association (AOA) are generally deemed to be compliant with the Centers 

for Medicare & Medicaid Services requirements. The document and table 

below include JCAHO and AOA requirements for hospitals that relate to

evacuation planning and emergency preparedness. The document includes 

JCAHO hospital requirements, and table 3 includes AOA hospital 

requirements. 

Page 30 GAO-06-826 Evacuation of Hospitals and Nursing Homes
Appendix III: JCAHO and AOA Requirements 

for Hospital Evacuation Planning and

Emergency Preparedness 

Page 31 GAO-06-826 Evacuation of Hospitals and Nursing Homes
Appendix III: JCAHO and AOA Requirements 

for Hospital Evacuation Planning and

Emergency Preparedness 

Page 32 GAO-06-826 Evacuation of Hospitals and Nursing Homes
Appendix III: JCAHO and AOA Requirements 

for Hospital Evacuation Planning and

Emergency Preparedness 

Page 33 GAO-06-826 Evacuation of Hospitals and Nursing Homes
Appendix III: JCAHO and AOA Requirements 

for Hospital Evacuation Planning and

Emergency Preparedness 

Page 34 GAO-06-826 Evacuation of Hospitals and Nursing Homes
Appendix III: JCAHO and AOA Requirements 

for Hospital Evacuation Planning and

Emergency Preparedness 

Page 35 GAO-06-826 Evacuation of Hospitals and Nursing Homes
Appendix III: JCAHO and AOA Requirements 

for Hospital Evacuation Planning and

Emergency Preparedness 

Page 36 GAO-06-826 Evacuation of Hospitals and Nursing Homes
Appendix III: JCAHO and AOA Requirements 

for Hospital Evacuation Planning and

Emergency Preparedness 

Page 37 GAO-06-826 Evacuation of Hospitals and Nursing Homes
Appendix III: JCAHO and AOA Requirements 

for Hospital Evacuation Planning and

Emergency Preparedness 

Page 38 GAO-06-826 Evacuation of Hospitals and Nursing Homes
Appendix III: JCAHO and AOA Requirements 

for Hospital Evacuation Planning and

Emergency Preparedness 

Page 39 GAO-06-826 Evacuation of Hospitals and Nursing Homes
Appendix III: JCAHO and AOA Requirements 

for Hospital Evacuation Planning and

Emergency Preparedness 

Source: JCAHO 2006 Hospital Accreditation Standards for Emergency Management Planning, Emergency Management Drills, 

Infection Control, and Disaster Privileges © 2005 Used with permission. 

Note: GAO obtained these standards from JCAHO in November 2005. According to JCAHO officials, 

parts of the standards have since been revised. 

Page 40 GAO-06-826 Evacuation of Hospitals and Nursing Homes
Appendix III: JCAHO and AOA Requirements 

for Hospital Evacuation Planning and

Emergency Preparedness 

Table 3: 2005 AOA Accreditation Requirements for Hospitals 

Standard Description

11.02.02 Building Safety. 

The condition of the physical plant and the 

overall hospital environment must be 

developed and maintained in such a manner

that the safety and well being of patients, 

visitors, and staff is assured. 

The hospital must ensure that the condition of the physical plant and overall hospital

environment is developed and maintained in a manner to ensure the safety and well 

being of patients. This includes ensuring that routine and preventive maintenance and 

testing activities are performed as necessary, in accordance with Federal and State 

laws, regulations, and guidelines and manufacturer’s recommendations, by 

establishing maintenance schedules and conducting ongoing maintenance inspections 

to identify areas or equipment in need of repair. The routine and preventive 

maintenance activities should be incorporated into the hospital’s QAPIa plan. 

The hospital must develop and implement a comprehensive plan to ensure that the 

safety and well being of patients are assured during emergency situations. The 

hospital must coordinate with Federal, State, and local emergency preparedness and 

health authorities to identify likely risks for their area (e.g., natural disaster,

bioterrorism threats, disruption of utilities such as water, sewer, electrical

communications, fuel; nuclear accidents, industrial accidents, and other likely mass 

casualties, etc.) and to develop appropriate responses that will assure that safety and 

well being of patients. 

The following issues should be considered when developing the comprehensive 

emergency plans: 

a. The differing needs of each location where the certified hospital operates 

b. The special needs of patient populations treated at the hospital (e.g., patients 

 with psychiatric diagnosis)

c. Security of patients and walk-in patients 

d. Security of supplies from misappropriation 

e. Pharmaceuticals, food, other supplies and equipment that may be needed 

 during emergency/disaster situations 

f. Communication to external entities if telephones and computers are not 

 operating emergency/disaster situations or become overloaded (e.g., ham 

 radio operators, community officials, other healthcare facilities if transfer of 

 patients is necessary, etc.) 

g. Communication among staff within the hospital itself 

h. Qualifications and training needed by personnel including healthcare staff, 

 security staff, and maintenance staff, to implement and carry out emergency 

 procedures

i. Identification, availability and notification of personnel that are needed to 

 implement and carry out the hospital’s emergency plans

j. Identification of community resources, including lines of communication and 

 names and contact information for community emergency preparedness 

 coordinators and responders 

k. Provisions if gas, water, electricity supply is shut off to the community 

l. Transfer or discharge of patients to home, other healthcare settings, or other 

 hospitals 

m. Transfer of patients with hospital equipment to another hospital or healthcare 

 setting; and

n. Methods to evaluate repairs needed and to secure various likely materials 

 and supplies to effectuate repairs 

Page 41 GAO-06-826 Evacuation of Hospitals and Nursing Homes
Appendix III: JCAHO and AOA Requirements 

for Hospital Evacuation Planning and

Emergency Preparedness 

Standard Description

11.07.01 Disaster Plans. 

Written disaster plans are developed, 

maintained, and available to the staff for crisis 

preparation 

All disaster plans written by a hospital should be reviewed and coordinated with local 

authorities so as to prevent confusion. Such authorities include, but are not limited to, 

civil authorities (such as fire department, police department, public health department 

or emergency medical service councils), and civil defense or military authorities. The 

hospital shall provide an education program for staff and physicians for emergency 

response preparedness. The hospital should also participate in community emergency 

preparedness plans. 

11.07.02 External Disaster Plan-Victim 

Triage. 

The hospital’s external disaster plan shall include the triaging of victims and includes 

at least: 

a. identification tags 

b. placement of patients 

c. notification of physicians; and 

d. preliminary diagnosis of patients 

The plan must address handling of communicable disease outbreaks and chemical

exposure victims. 

11.07.03 Disaster Drills. Disaster drills are to be performed at least semiannually one of which shall include the 

community. 

11.08.03 Maintenance Ensures Safety and 

Quality. 

Facilities must be maintained to ensure an acceptable level of safety and quality. 

Facilities, supplies, and equipment shall be 

maintained to ensure an acceptable level of

safety and quality. 

Supplies must be maintained to ensure an acceptable level of safety and quality. This 

would include that supplies are stored in such a manner to ensure the safety of the 

stored supplies (protection against theft or damage, contamination, or deterioration), 

as well as, that the storage practices do not violate fire codes or otherwise endanger 

patients (storage of flammables, blocking passageways, storage of contaminated or 

dangerous materials, safe storage practices for poisons, etc.) 

Additionally, “supplies must be maintained to ensure an acceptable level of safety” 

would include that the hospital identifies the supplies it needs to meet its patients’ 

needs for both day-to-day operations and those supplies that are likely to be needed in

likely emergency situations such as mass casualty events resulting from natural

disasters, mass trauma, disease outbreaks, etc.; and that the hospital makes 

adequate provisions to ensure the availability of those supplies when needed. 

Medical equipment and other equipment must be maintained in accordance with 

manufacturers recommendations, laws, and NFPAb

 99 chapters as appropriate. 

Equipment includes both hospital equipment (e.g., elevators, generators, air handlers, 

medical gas systems, air compressors and vacuum systems, etc.) and medical 

equipment (e.g., biomedical equipment, radiological equipment, patient beds, 

stretchers, IV infusion equipment, ventilators, laboratory equipment, etc.). 

There must be a regular periodical maintenance and testing program for medical

devices and equipment. A qualified individual such as a clinical or biomedical

engineer, or other qualified maintenance person must monitor, test, calibrate and 

maintain the equipment periodically in accordance with the manufacturer’s

recommendations and federal and State laws and regulations. Equipment 

maintenance may be conducted using hospital staff, contracts, or through a 

combination of hospital staff and contracted services. 

Page 42 GAO-06-826 Evacuation of Hospitals and Nursing Homes
Appendix III: JCAHO and AOA Requirements 

for Hospital Evacuation Planning and

Emergency Preparedness 

Standard Description

“Equipment must be maintained to ensure an acceptable level of safety” would include 

that the hospital identifies the equipment it needs to meet its patients’ needs for both 

day-to-day operations and equipment that is likely to be needed in likely 

emergency/disaster situations such as mass casualty events resulting from natural 

disasters, mass trauma, disease outbreaks, internal disasters, etc.; and that the 

hospital makes adequate provisions to ensure the availability of that equipment when

needed. 

Source: Accreditation Requirements for Healthcare Facilities © 2005, Healthcare Facilities Accreditation Program (HFAP) of the 

American Osteopathic Association. Used with permission. 

a

Quality assessment performance improvement. 

b

National Fire Protection Association. 

Page 43 GAO-06-826 Evacuation of Hospitals and Nursing Homes
Appendix IV: Comments from the Department Appendix IV of Homeland Security : Comments from the 

Department of Homeland Security 

Page 44 GAO-06-826 Evacuation of Hospitals and Nursing Homes
Appendix IV: Comments from the Department 

of Homeland Security

Page 45 GAO-06-826 Evacuation of Hospitals and Nursing Homes
Appendix V: Comments from the Department Appendix V of Defense : Comments from the Department 

of Defense 

Page 46 GAO-06-826 Evacuation of Hospitals and Nursing Homes
Appendix V: Comments from the Department 

of Defense 

Page 47 GAO-06-826 Evacuation of Hospitals and Nursing Homes
Appendix VI: Comments from the Department Appendix VI: Comments from the of Health and Human Services 

Department of Health and Human Services 

Page 48 GAO-06-826 Evacuation of Hospitals and Nursing Homes
Appendix VII: Comments from the Appendix VII: Comments from the Department of Veterans Affairs 

Department of Veterans Affairs 

Page 49 GAO-06-826 Evacuation of Hospitals and Nursing Homes
Appendix VIII: 

A

GAO Contact and Staff 

cknowledgments 

Page 50 GAO-06-826

Appendix VIII: GAO Contact and Staff 

Acknowledgments 

GAO Contact Cynthia A. Bascetta at (202) 512-7101 or bascettac@gao.gov 

In addition to the contact named above, key contributors to this report 

were Linda T. Kohn, Assistant Director; La Sherri Bush; Krister Friday; 

Nkeruka Okonmah; and William Simerl. 

Acknowledgments 

Evacuation of Hospitals and Nursing Homes
Related GAO Products Related GAO Products 

Disaster Preparedness: Preliminary Observations on the Evacuation of 

Vulnerable Populations due to Hurricanes and Other Disasters. GAO-06-

790T. Washington, D.C.: May 18, 2006. 

Hurricane Katrina: Status of the Health Care System in New Orleans 

and Difficult Decisions Related to Efforts to Rebuild It Approximately 6 

Months After Hurricane Katrina. GAO-06-576R. Washington, D.C.: 

March 28, 2006. 

Hurricane Katrina: GAO’s Preliminary Observations Regarding 

Preparedness, Response, and Recovery. GAO-06-442T. Washington, D.C.: 

March 8, 2006. 

Disaster Preparedness: Preliminary Observations on the Evacuation of 

Hospitals and Nursing Homes Due to Hurricanes. GAO-06-

443R. Washington, D.C.: February 16, 2006. 

HHS Bioterrorism Preparedness Programs: States Reported Progress but 

Fell Short of Program Goals for 2002. GAO-04-360R. Washington, D.C.: 

February 10, 2004. 

Bioterrorism: Public Health Response to Anthrax Incidents of 2001. 

GAO-04-152. Washington, D.C.: October 15, 2003. 

Hospital Preparedness: Most Urban Hospitals Have Emergency Plans 

but Lack Certain Capacities for Bioterrorism Response. GAO-03-924. 

Washington, D.C.: August 6, 2003. 

Bioterrorism: Information Technology Strategy Could Strengthen 

Federal Agencies’ Abilities to Respond to Public Health Emergencies. 

GAO-03-139. Washington, D.C.: May 30, 2003. 

Bioterrorism: Preparedness Varied across State and Local Jurisdictions. 

GAO-03-373. Washington, D.C.: April 7, 2003. 

(290503) Page 51 GAO-06-826 Evacuation of Hospitals and Nursing Homes
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