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[Senate Hearing 115-379]
[From the U.S. Government Publishing Office]

                                                        S. Hrg. 115-379
 
    DISASTER PREPAREDNESS AND RESPONSE: THE SPECIAL NEEDS OF OLDER 
                               AMERICANS

=======================================================================

                                HEARING

                               BEFORE THE

                       SPECIAL COMMITTEE ON AGING

                          UNITED STATES SENATE

                     ONE HUNDRED FIFTEENTH CONGRESS

                             FIRST SESSION

                               __________

                             WASHINGTON, DC

                               __________

                           SEPTEMBER 20, 2017

                               __________

                            Serial No. 115-9

         Printed for the use of the Special Committee on Aging
         
         
         
         
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]         

        Available via the World Wide Web: http://www.govinfo.gov
        
        
        
                               _________ 

                   U.S. GOVERNMENT PUBLISHING OFFICE
                   
 30-022 PDF                  WASHINGTON : 2018              
        
        
        
                       SPECIAL COMMITTEE ON AGING

                   SUSAN M. COLLINS, Maine, Chairman

ORRIN G. HATCH, Utah                 ROBERT P. CASEY, JR., Pennsylvania
JEFF FLAKE, Arizona                  BILL NELSON, Florida
TIM SCOTT, South Carolina            SHELDON WHITEHOUSE, Rhode Island
THOM TILLIS, North Carolina          KIRSTEN E. GILLIBRAND, New York
BOB CORKER, Tennessee                RICHARD BLUMENTHAL, Connecticut
RICHARD BURR, North Carolina         JOE DONNELLY, Indiana
MARCO RUBIO, Florida                 ELIZABETH WARREN, Massachusetts
DEB FISCHER, Nebraska                CATHERINE CORTEZ MASTO, Nevada
                              ----------                              
                 Kevin Kelley, Majority Staff Director
                  Kate Mevis, Minority Staff Director
                  
                  
                                CONTENTS

                              ----------                              

                                                                   Page

Opening Statement of Senator Susan M. Collins, Chairman..........     1
Statement of Senator Robert P. Casey, Jr., Ranking Member........     3
Statement of Senator Thom Tillis.................................     5

                           PANEL OF WITNESSES

Karen B. DeSalvo, M.D., Former Health Commissioner, City of New 
  Orleans, New Orleans, Louisiana................................     6
Kathryn Hyer, Ph.D., Professor and Director, Florida Policy 
  Exchange Center on Aging, School of Aging Studies, University 
  of South Florida, Tampa, Florida...............................     9
Paul Timmons, President, Portlight Inclusive Disaster Strategies, 
  Inc., Charleston, South Carolina...............................    11
Jay Delaney, Fire Chief and Emergency Management Coordinator, 
  City of Wilkes-Barre, Wilkes-Barre, Pennsylvania...............    12

                                APPENDIX
        Prepared Witness Statements and Questions for the Record

Karen B. DeSalvo, M.D., Former Health Commissioner, City of New 
  Orleans, New Orleans, Louisiana................................    30
    Questions submitted for Karen B. DeSalvo.....................    33
Kathryn Hyer, Ph.D., Professor and Director, Florida Policy 
  Exchange Center on Aging, School of Aging Studies, University 
  of South Florida, Tampa, Florida...............................    36
    Questions submitted for Kathryn Hyer.........................    38
Paul Timmons, President, Portlight Inclusive Disaster Strategies, 
  Inc., Charleston, South Carolina...............................    42
    Questions submitted for Paul Timmons.........................    45
Jay Delaney, Fire Chief and Emergency Management Coordinator, 
  City of Wilkes-Barre, Wilkes-Barre, Pennsylvania...............    47

                  Additional Statements for the Record

Senator Marco Rubio, Statement for the Record....................    50
Katie Smith Sloan, President and CEO, LeadingAge.................    50
James R. Balda, President and CEO, Argentum......................    52
Teresa Osborne, Pennsylvania Secretary of Aging, and Rick Flinn, 
  Director, Pennsylvania Emergency Management Agency.............    56

    DISASTER PREPAREDNESS AND RESPONSE: THE SPECIAL NEEDS OF OLDER 
                               AMERICANS

                              ----------                              

                     WEDNESDAY, SEPTEMBER 20, 2017

                                       U.S. Senate,
                                Special Committee on Aging,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 9:06 a.m., in 
Room SD-562, Dirksen Senate Office Building, Hon. Susan Collins 
(Chairman of the Committee) presiding.
    Present: Senators Collins, Tillis, Fischer, Casey, 
Gillibrand, Donnelly, and Cortez Masto.

    OPENING STATEMENT OF SENATOR SUSAN M. COLLINS, CHAIRMAN

    The Chairman. The Committee will come to order.
    Good morning. Recently, Hurricanes Harvey and Irma left a 
path of destruction along the gulf coast of Texas, across 
Florida, and throughout the Caribbean. Homes, businesses, and 
entire communities were destroyed and lives were lost.
    Days after Irma, we learned the tragic news that eight 
seniors, ranging in age from 71 to 99, died in a Florida 
nursing home that lacked air conditioning because the power had 
been knocked out. One press account described the facility as 
``a death trap'' because the elderly are particularly 
susceptible to heat-related illnesses. Last month, this photo 
of residents of an assisted living facility in Texas who were 
trapped in waist-deep water went viral.
    As these recent disasters make clear, older Americans are 
particularly vulnerable before, during, and even after a storm. 
In fact, when Hurricane Katrina slammed into the gulf coast 12 
years ago, more than half of those who died were seniors.
    As the then Chair of the Senate Homeland Security 
Committee, along with Senator Joe Lieberman of Connecticut, I 
led a bipartisan investigation into the response to Hurricane 
Katrina at the federal, state, and local levels. Our 
investigation, which resulted in this extensive, some would say 
weighty report, revealed many weaknesses in our Nation's 
emergency response system, and although I doubt very many 
people read the whole report, it does have an excellent summary 
that I was just discussing with the chief. And it was evident 
to me in rereading it that we have learned many of the lessons 
of Katrina, but we still have a long ways to go.
    One of the weaknesses in our Nation's emergency response 
system included the failure on the part of all levels of 
government to plan and provide for timely and effective 
evaluation of our most vulnerable seniors. Since then, we have 
expanded our efforts to improve emergency preparedness and 
response across the entire country, and we have emphasized the 
protection of the most vulnerable.
    Meanwhile, Mother Nature continues to unleash her fury. 
Today, even as we meet, yet another hurricane, Maria, is 
battering a region still struggling to recover, and it is 
expected to hit Puerto Rico particularly hard.
    This morning, we will discuss how our federal, state, and 
local emergency response efforts have been critical in limiting 
the scope of these recent tragedies, and we will identify where 
more work is still needed.
    On the positive side, improvements in emergency response 
efforts at the Centers for Medicare & Medicaid Services have 
helped to identify those seniors who require relocation in 
order to maintain their dialysis. I was talking with the head 
of CMS just yesterday about this, and she said one of the 
problems was that the demand was so great that people were not 
able to have complete dialysis. They were hooked up to the 
machines for 2 hours when they needed a far longer period of 
time, but the demand was such that they were just trying to 
maintain people.
    In addition, local emergency response teams implemented 
strategies to identify those most in need and provided 
designated shelters that offered necessary medical care and 
support. But that, tragically, was not always the case. The 
lack of electrical power apparently contributed to the death of 
those seniors in the nursing home and to the worsening health 
condition of others, suggesting a very troubling lack of 
preparedness in some health care centers.
    While we have made many strides since Hurricane Katrina 
twelve years ago, we must ask ourselves: Can we better protect 
the most vulnerable members of our communities? What gaps exist 
that could jeopardize lives in the next catastrophe, whether it 
is a storm, an earthquake, or some other unanticipated event? 
We should not have to wait for the next Irene, Sandy, Harvey, 
Irma, or unnamed disaster to strike.
    Today we will discuss concrete solutions to protect and 
stabilize vulnerable seniors from maintaining necessary 
resources and connections during emergencies to relocating and 
returning to safe and secure homes during the recovery period. 
We will consider the challenges of making the correct choices 
of whether it is better to shelter people in place or evacuate 
and relocate. And as I have looked more into this issue, I have 
learned that that is often a very difficult decision to make, 
particularly if you are dealing with people with some sort of 
dementia.
    Just one day after Hurricane Irma slammed much of Florida, 
a CNN reporter waded about a mile in waist-deep water, 
contaminated with oil and garbage, to knock on the door of a 
mobile home in Bonita Springs. He had been told that an elderly 
couple lived inside and that they did not heed the warnings of 
local and state officials to leave prior to the storm. Inside 
this mobile home, which was now surrounded by water, lived an 
88 year-old woman and her 93 year-old husband who suffered from 
Parkinson's disease and diabetes. When the reporter asked the 
woman why they did not evacuate, she simply replied: ``We have 
everything we need here. We have his medications. It is just 
easier.''
    Now, I am very grateful that this couple was found safe, 
but to me this story illustrates how we must expand our efforts 
to protect vulnerable seniors, not only those who are living in 
facilities such as assisted living or long-term care 
facilities, but instead are living in their own homes. For many 
of those seniors, evacuation is not as easy as packing a bag 
and jumping into a car. They may not be able to drive, for 
example. Some of these homebound older adults are alone and 
frail. They may suffer from diseases. And many of them have 
lived in their homes for so long that they just do not want to 
leave it behind and are fearful of what will happen if they 
leave.
    Let me conclude by offering my condolences to all those who 
experienced losses as a result of these violent hurricanes. My 
heart goes out to all of those who are suffering and now face 
the considerable challenges in the weeks and months ahead.
    I also want to extend my gratitude to the first responders, 
including the volunteers, such as a medical team from Maine and 
everyone who has reached out to help a neighbor in need, even 
as in so many cases they, too, are dealing with the devastation 
caused by these terrible storms. While we can and must continue 
to improve our emergency response so that the tragic deaths in 
Florida's nursing homes do not happen in the future, we should 
not overlook the heroic actions of so many.
    I want to thank our witnesses for being with us today, and 
I am delighted to now recognize the Ranking Member, Senator 
Casey.

  OPENING STATEMENT OF SENATOR ROBERT P. CASEY, JR., RANKING 
                             MEMBER

    Senator Casey. Chairman Collins, thank you very much for 
having this very important hearing, especially at this time.
    I join the Chairman in thanking the work of those who have 
done emergency response tasks over many, many days now. The 
countless volunteers who have helped them throughout these many 
days of challenge, we are grateful for that work, and we join 
in thanking them for doing that great work.
    Together they have worked endless hours over these last 
several weeks to save the lives of people in Texas, in Florida, 
the U.S. Virgin Islands, and now, of course, folks in Puerto 
Rico are facing a difficult number of days ahead; and we are 
thinking of them and praying for them at this time. To say that 
these actions have been heroic is an understatement. There is 
no way to adequately describe that kind of commitment, that 
kind of heroism.
    But, unfortunately, today we are here because we know that, 
despite great efforts by a lot of good people across the 
country, older Americans and individuals with disabilities face 
extraordinary challenges in a disaster. And, again, that is an 
understatement. So many of us were both outraged and enraged 
when we saw what happened in Florida, that people died, seniors 
died in the midst of this crisis. We are also heartbroken for 
the loss of life and also the loss that those families 
suffered. In this case it was apparently something as simple as 
a lack of air conditioning--something that many of us take for 
granted just even on a day like today in this building. It is 
hard to comprehend the sadness that will engulf those families 
and those communities. So that is one of many challenges we 
will speak to today.
    Just yesterday, Senator Nelson, who has done great work in 
his home State of Florida dealing with these issues, said the 
following, he said: ``One life lost is one too many.''
    I am proud--and I know that Chairman Collins as well is 
proud--that we have joined him in introducing legislation that 
would do the following: It would require the Secretary of 
Health and Human Services to establish a national advisory 
committee on seniors and disasters. A 15-member panel would be 
appointed by the Secretary of HHS and made up of federal and 
local agency officials as well as non-federal health care 
professionals with expertise in disaster response. It is a good 
bill. It is bipartisan. We should pass it. Both Senator Nelson 
and Senator Rubio have introduced it. So that is one thing that 
we can do together to better plan for and respond to these 
challenges in the future.
    But like all Americans, and I think every American was 
stunned by the viral photo that the Chairman just showed of one 
nursing home and the water that was rising around those 
seniors, in this case in an assisted living facility in Houston 
where they were sitting in waist-deep water waiting to be 
rescued.
    These are folks who, indeed, to say they are our greatest 
generation does not adequately capture it. These are folks who 
fought our wars; they worked in our factories; they built the 
middle class; they gave us the kind of life that we take for 
granted sometimes. They have sacrificed so much, and they have 
lived lives of quiet dignity. We have a sacred obligation to 
them to make sure those scenes that were depicted in that 
photograph and that happened in Florida never happen again.
    Just as the Chairman said, all the good lessons that were 
learned in the aftermath of Katrina, we have to implement 
better practices, best practices to make sure that we learn 
from these recent disasters as well. So we need to ensure that 
we are doing everything possible to learn from these tragedies, 
and we also have to make sure that we are focused, on a day 
like today, on better policy. And that is why we gather today 
with such a great panel of witnesses.
    These witnesses bring not just experiences from the recent 
past, but in many cases from years of experience, from 
Hurricane Katrina to Hurricane Harvey. They have faced the 
double whammy, so to speak, of Hurricanes Lee and Irene back in 
2011, as well as the four hurricanes in 6 weeks that ravaged 
Florida in the year 2004.
    We have learned--and they have learned even more--from each 
of these experiences. So we hear from our witnesses, incident 
management infrastructure is more robust in some important 
areas like hospitals. That is good news, That means we have 
learned lessons to implement those changes. Coordination 
efforts in advance of storms have been improved, and there are 
more comprehensive emergency response requirements being 
implemented for nursing homes so that seniors will be better 
protected.
    But we have a long way to go to make sure that we get this 
right. Older citizens should not suffer for days and then die 
in the unbearable heat. No person with a disability should have 
trouble following evacuation orders because of inaccessible 
transportation or shelters. And it should go without saying no 
senior should fear drowning in their own home, no matter where 
they live.
    Our witnesses here today will explain how we can do better, 
because we must do better. We have a sacred obligation to do 
better.
    I want to thank the witnesses for bringing their 
experiences, their expertise, and their passion to these 
issues. And I want to thank Chairman Collins for gathering us 
on this day.
    The Chairman. Thank you very much, Senator Casey.
    I am delighted that we have Senator Tillis, Senator 
Fischer, and Senator Cortez Masto here with us today, and I 
very much appreciate their participation. I know that Senator 
Tillis has to get off to the Judiciary Committee, and so I 
would like to offer him the opportunity for any comments he 
would like to make.

            OPENING STATEMENT OF SENATOR THOM TILLIS

    Senator Tillis. Thank you, Madam Chair. I do have to chair 
the Judiciary Committee, so once I get there, I will not be 
able to come back. But I wanted to thank you all for being 
here. The building is a little empty today because we adjourned 
last night, but you see the focus that these members have to be 
here, and thank you all for being here.
    You know, I am glad that we framed this as really a 
response to disaster. We are going to immediately leap to the 
disaster that right now is occurring in Puerto Rico with Maria 
making landfall with 175 mile per-hour sustained winds. We can 
talk about the recent storms Harvey and Irma, but I could talk 
about an enormous impact in North Carolina called Matthew a 
year ago on October 8th. And I have a personal story to tell 
there because our office, our staff had to help a senior who 
had gotten lost in the process, who had left her home, as she 
should have. We had almost 20 inches of rainfall in about a 24-
hour period that was devastating to the community, and then the 
river rises afterward were even worse, so much so that when 
they would go to one shelter, that shelter got closed down 
because the water threatened those shelters.
    And so it really raised a question, Mr. Timmons--I am going 
to submit some questions for the record for all of you to 
potentially respond to, but it raises a question about how well 
we track evacuees through the life cycle. And I think that life 
cycle needs to go before the disaster ever occurs and then 
until there is a resolution that makes us feel like that senior 
is safe and secure.
    I think one of the reasons that we have a challenge with 
evacuating seniors is they just have a fear of the unknown. And 
if we did a better job of communicating what this would look 
like earlier, where they are likely to go, and how we are going 
to be stewards of them over the course of the process, then I 
think that many who feel like the safest thing to do is to 
shelter in place will be replaced with a sense of comfort that 
they are going to be taken care of through the process, up to 
and including getting them back into their home and living 
independently again or living in a facility where they have 
been taken care of.
    So that life cycle, where it needs to start, how do we 
better educate, how do we better link--what we ended up doing 
in our office is gluing together--and I think it can be 
instructive for things that we need to do differently. But, 
fortunately, our Governor, our emergency management folks in 
North Carolina helped us find this lady, get her medications, 
which were desperately needed, and get her connected to her 
family. So that sort of life cycle of disaster that starts 
before the disaster ever occurs, until we know that that senior 
is safe and sound, is something that I think would be very 
helpful and instructive to us to see how we can actually work 
at the federal, state, and local level to make that happen.
    Thank you all for being here, and thank you for being 
focused on helping us come up with a solution. And, again, 
Madam Chair, thank you for your work on this subject.
    The Chairman. Thank you very much, Senator Tillis.
    I am now going to introduce our excellent panel of 
witnesses.
    First is Dr. Karen DeSalvo. Dr. DeSalvo is a physician and 
public health expert. She served as health commissioner in New 
Orleans, where she worked hard to restore health care to areas 
of the city devastated by Hurricane Katrina. She has also 
served as the former Assistant Secretary for Health at the U.S. 
Department of Health and Human Services.
    Next we will hear from Dr. Kathy Hyer. Dr. Hyer is director 
of the Florida Policy Exchange Center on Aging at the 
University of South Florida. Dr. Hyer has researched and 
written extensively about vulnerable older Americans and the 
structure of the emergency response systems. I want to 
particularly thank you, Dr. Hyer, for being here today even as 
the long recovery process in Florida continues.
    We will also hear from Paul Timmons. Mr. Timmons is 
president of Portlight Inclusive Disaster Strategies in 
Charleston, South Carolina. Despite that mouthful of an 
organization's name, he is a leader in the field of disaster 
preparedness and response for people who are aging and those 
with disabilities.
    Finally, I am going to turn to our Ranking Member to 
introduce our witness from Pennsylvania.
    Senator Casey. Thanks very much. I am pleased to introduce 
Jay Delaney, who is fire chief and emergency management 
coordinator for the city of Wilkes-Barre, Pennsylvania. Chief 
Delaney led the response efforts when it became clear that 
Hurricanes Irene and Lee could cause the Susquehanna River, the 
16th largest river in the United States, to overwhelm our 
levees in the community of Wilkes-Barre, Pennsylvania. With the 
clock ticking and the waters rising, Chief Delaney safely 
evacuated 15,000 people in just 10 hours, including our 
hospitals and nursing homes. I look forward to the chief's 
testimony. Thanks, Chief.
    The Chairman. Thank you very much, Senator.
    We will start with Dr. DeSalvo.

      STATEMENT OF KAREN B. DeSALVO, M.D., FORMER HEALTH 
   COMMISSIONER, CITY OF NEW ORLEANS, NEW ORLEANS, LOUISIANA

    Dr. DeSalvo. Thank you, and good morning, Chairman Collins 
and Ranking Member Casey and distinguished members of the 
Committee. Thank you all for making time in a very busy agenda 
of the Senate to talk about this priority issue of seeing that 
we have an opportunity to better support and protect older 
Americans in times of disaster and every day. I am Karen 
DeSalvo. I am a physician, and I was formerly the health 
commissioner in New Orleans--not during the time of Katrina but 
subsequently, and I certainly was in New Orleans at Katrina. 
But I want to share a story that started a little bit later.
    It was 2012, and I found myself standing in the Emergency 
Operations Center in New Orleans being asked by our power 
company how to prioritize power restoration for our community. 
I was relatively new to the job. It was August. It was hot. We 
knew that we were just about 7 years after Katrina, and though 
we had done very much to heed the advice of better preparations 
and planning, what we had is an event that was not about 
flooding but was actually about power outage from prolonged 
high winds.
    We were prepared in many ways. We had hardened the 
infrastructure, particularly of our hospitals. We have better 
relationships, particularly heeding the advice of Senator 
Collins of not exchanging business cards during disaster but 
doing it well before. And we had done much better planning. In 
fact, our hospitals had returned to normal functioning.
    The question I was being asked to address was how to 
prioritize power for the rest of the community, and the 
situation was complicated, of course, because we were getting 
reports of seniors struggling in the heat throughout our 
community. And we had offered evacuation assistance to many of 
those seniors who had been registered in our medical special 
needs registry, but they wanted to shelter in place and did not 
take the opportunity to voluntarily evacuate.
    Though we knew some about them, we did not know where they 
were clustered and who was at highest risk and who was 
electricity dependent. And so in the end I resorted going door 
to door throughout our community to try to help prioritize 
power restoration based upon who answered the door when we 
knocked on it.
    We were able to help a lot of people because we did this 
with the support of first responders like fire, but it was not 
a great feeling, nor was it very efficient. And so going 
forward, we did not want to repeat that experience of having to 
be somewhat haphazard in trying to determine how to restore 
power in our community, and we worked with HHS to leverage 
Medicare data and new technologies like geomapping to be able 
to create a map in our community of where seniors who are 
electricity-dependent lived.
    We did a drill in the community with fire and police and 
volunteers and went door to door to the dots on this map, a 
subset of them, knocked on the door, and said, ``We are from 
the government, and we are here to help.'' We actually did say 
that. I did. And people willingly opened their doors and 
learned that we were trying to find out if they were 
electricity-dependent and how we could be helpful for them not 
only in disaster but every day.
    We learned the Medicare data worked. It was accurate. And 
we also learned something perhaps more concerning: that of the 
some 600 people who were on the list as electricity dependent 
for their oxygen, we only knew of 15 of them in our medical 
special needs registry.
    That system, called ``emPOWER,'' has been taken to scale 
and is available to be used across the country in every 
community, not only in disaster response but also in 
preparedness. And it is an example of how we can use technology 
and local experiences married with federal resources to really 
do better in preparedness and response. And, in fact, HHS 
recently used this tool in Irma and in Harvey.
    We do tend to focus on those disasters that make the 
headlines and also on those who are most frail and in nursing 
homes, but I just want to take a moment to talk about 
additional important work that we need to do beyond supporting 
those most frail in our community that are in institutions.
    When I went door to door in the community after Isaac, the 
bulk of the people I saw were individuals that were living 
independently, in community-based settings, often in subsidized 
housing and high-rises. And, frankly, what I saw was really 
heartbreaking. These are people who are living on the edge 
every day and are not likely to be broken only by a major 
disaster but by, frankly, all the little disasters that touch 
their lives on a regular basis. And tools like emPOWER are a 
great way to get them on a medical special needs registry so we 
know how to find them, but they require human touch as well, 
and that is part of the resiliency building that we all need to 
do.
    I agree that since Katrina we have made a great deal of 
progress in hardening our infrastructure, in building the 
relationships that are necessary to help us better prepare and 
respond, but there is so much we still need to do to support 
our seniors. And in that vein I offer actions in three areas 
that I think can help build a stronger infrastructure. There is 
more in my testimony, but I will just highlight a few today.
    One, is tools like emPOWER remind us that we have now 
technology and data, but it is only as good as the data in it. 
So, for example, in emPOWER, if we expanded it to include 
Medicaid and commercially insured populations, we could do more 
good for more people. And Congress needs to support the action 
on the ground. It is one thing to have information in a box, 
but we have to also be able to act upon it on the front lines, 
and that requires training exercises perhaps with local public 
health and the Public Health Service Commission Corps.
    Second, we need to support the local public health and 
response infrastructure. They are under-resourced to meet their 
statutory obligations to support the community and the most 
vulnerable in times of need. This includes public health, but 
other agencies and the private sector who are trying to help 
seniors and older Americans every day.
    Third, we need to do more to protect. I think the CMS 
Emergency Preparedness Rule is a step towards strengthening the 
infrastructure, but it requires robust implementation. It is 
not pieces of paper and checklists. It is actually really 
drilling and paying attention in an ongoing fashion to things 
like fuel supplies for generators.
    And, finally, I think the administration should think about 
creating best practices tools that can help guide policy and 
regulation and local ordinances that can support areas that 
sometimes we forget about for preparedness like building codes.
    Thank you again for raising the profile of the need to 
better support seniors, older Americans, and the most 
vulnerable in our community in times of disaster, but also 
every day, and I look forward to your questions.
    The Chairman. Thank you very much, Doctor.
    Dr. Hyer.

   STATEMENT OF KATHRYN HYER, PH.D., PROFESSOR AND DIRECTOR, 
   FLORIDA POLICY EXCHANGE CENTER ON AGING, SCHOOL OF AGING 
      STUDIES, UNIVERSITY OF SOUTH FLORIDA, TAMPA, FLORIDA

    Dr. Hyer. Good morning. On behalf of my colleague Dr. David 
Dosa, who could not be here today, I want to thank all of you 
for being here and for giving me the opportunity to testify on 
a topic I have studied since 2004 when four hurricanes 
traversed Florida in 44 days. Since that time, my colleagues 
and I have studied the effect of disasters on frail older 
adults and disabled individuals living in nursing homes and 
assisted living, and we have worked to improve disaster 
preparedness, response, and readiness.
    My remarks reflect more than a decade's worth of research 
that has been carried out with generous grants from the John A. 
Hartford Foundation, the Kaiser Foundation, the Borchard 
Foundation, and the National Institutes of Health, 
specifically, the National Institute on Aging.
    In 2004, as Senator Collins alluded to, nursing homes only 
became part of the State Emergency Response System after 
repeated hurricanes crisscrossed the State, and emergency 
personnel finally recognized that nursing homes were actually 
health care facilities, taking care of frail elders. ESF 
recognized nursing homes needed help getting fuel for 
generators, getting power restored. Only then were nursing 
homes recognized as part of the health care provider system. 
They were ignored until then.
    Following Katrina, our research team interviewed nursing 
home administrators about their experience during Katrina. 
Across the board these nursing home administrators revealed 
that they wrestled with the important decision about whether to 
evacuate their residents prior to the storm. They cited 
pressure from emergency managers urging them to evacuate 
despite the difficulty of evacuation, having elders pushed on 
buses, having them evacuate to gymnasiums without supplies and 
adequate materials and mattresses. And they recognized that 
these patients declined. They saw their own staff hurt trying 
to help and move residents. And they believed that they would 
be better served staying where they are.
    This initial work became the impetus for the National 
Institute of Aging's study that we did looking at the effects 
of Hurricanes Katrina, Rita, Gustav, and Ike on nursing home 
residents. Our research showed that among 36,000 nursing home 
residents exposed to those gulf hurricanes, the 30- and 90-day 
mortality and hospitalization rates increased considerably 
compared to the non-hurricane control years regardless of 
whether they evacuated or sheltered in place. In total, there 
were 277 extra deaths and 872 extra hospitalizations within 30 
days after exposure to the storms. Natural disasters result in 
bad outcomes for elderly and disabled individuals.
    Our research, however, asked a second question. We asked 
whether or not it was better to evacuate or shelter in place. 
Using those same data from those four storms and methodological 
techniques that are in the appendix that we have provided, our 
research concluded that the very act of evacuation prior to the 
storm increased the probability of death at 90 days and 
increased the risk of hospitalization, independent of all other 
factors. It should be noted that our data took into account the 
fact of certain nursing homes that did not evacuate, including 
St. Rita's and Lafon Nursing Homes where there were, 
tragically, many deaths.
    Despite these tragic deaths, evacuation proved to be 
cumulatively more dangerous than sheltering in place. Based on 
our research and our experience, we have the following 
recommendations:
    We need generators to support medical needs and air 
conditioning to cool reasonable temperatures as well as fuel 
for both nursing homes and assisted livings. These generators 
need to be elevated to ensure continued operation. Emergency 
plans for both nursing homes and assisted livings must be 
publicly and easily available for all to see and for residents 
and families to understand before they enter a nursing home.
    Nursing home surveyors and emergency managers also need to 
be sure all plans are actually tested, and this means real 
drills and actual implementation.
    Assisted living communities require much more oversight. 
Assisted living communities routinely accept patients who would 
have received care in a nursing home only a decade ago.
    Waiver payments for residents with Medicaid have also 
increased, thereby making the Federal Government at least an 
interested party in assisted living regulations.
    Evacuations should not be all or nothing. Senator Collins 
already talked about the importance of dialysis residents being 
evacuated. We need a much more nuanced and better researched 
understanding of who should evacuate before and then how people 
can be sustained appropriately.
    Nursing homes and assisted livings must be built in places 
that minimize flooding, and they have to be built to standards 
that allow administrators to shelter in place if at all 
possible.
    Every state and local emergency management organization in 
this country must identify and prioritize nursing homes and 
assisted living communities for restoration of power services 
and other services.
    Some degree of litigation protection must be considered for 
facilities that abide by regulations and provide heroic care 
during disaster scenarios. There are many people working very 
hard to try to care for elders and disabled people all over 
Florida, continuing as we speak.
    Finally, older adults matter. I am the PI on a HRSA 
Geriatric Workforce Enhancement Program grant. We need 
continued commitment to geriatric education programs and 
training programs. I can only provide the evidence I am 
providing today because research and training was approved 
years ago, but it dried up in the years following Katrina. Our 
country needs ongoing geriatric training. We need consistent 
research funding to evaluate disasters. We know that disasters 
will continue to occur, and we must be prepared.
    Thank you for allowing this testimony, and I look forward 
to questions.
    The Chairman. Thank you very much.
    Mr. Timmons.

   STATEMENT OF PAUL TIMMONS, PRESIDENT, PORTLIGHT INCLUSIVE 
     DISASTER STRATEGIES, INC., CHARLESTON, SOUTH CAROLINA

    Mr. Timmons. Thank you, and good morning. Portlight is the 
Nation's only NGO with a specific mission to serve the disaster 
relief needs of people with disabilities and older Americans. 
Portlight is a 20-year-old grassroots organization with a proud 
history of serving on the ground in virtually every major 
national disaster since Hurricane Katrina. Our Partnership for 
Inclusive Disaster Strategies leads and coordinates over 100 
disability, aging, emergency, public health, public safety, and 
other local, State, and national stakeholder groups, including 
FEMA and the Red Cross, with a shared commitment to the 
emergency preparedness and disaster-related needs of the 
Nation's 59 million people with disabilities and 67 million 
Americans over the age of 60.
    We have been convening stakeholder calls daily to identify 
problems and find solutions and operating our hotline to assist 
disaster survivors from Harvey and Irma, and we are currently 
preparing our incredibly dedicated volunteers for Hurricane 
Maria.
    Given that people with disabilities and older adults are 
two to four times more likely to die or be seriously injured in 
a disaster, the urgency of our work cannot be understated. This 
is due frequently to poor planning, inadequate accessibility, 
and the widely shared but incorrect assumption that people with 
disabilities and older adults are ``vulnerable,'' ``special,'' 
or ``particularly at risk'' simply because of their diagnoses 
or stigmatizing beliefs about disability and aging. In fact, we 
are extremely valuable experts on emergency problem solving, 
with far more practice than younger people and people who do 
not navigate inaccessible environments and programs on a daily 
basis.
    The appropriate approach focuses broadly on the access and 
functional needs of people with and without legal disability 
rights protections. In a disaster, providing equal access and 
meeting functional needs makes the difference time and again 
for individuals, families, and communities. In fact, the phrase 
``people with access and functional needs'' has been codified 
by DHS and is the work term of art among emergency management 
professionals, and it perfectly fits our discussion here.
    Ineffective and inappropriate evacuation, hospitalization, 
nursing home admission, and separate sheltering and strategies 
for assisting millions of people with access and functional 
needs might look right on papers; however, it is a deeply 
flawed approach in practice, and it must be stopped. It has 
been clearly proven in story after disturbing story to be even 
worse than we expected. Here are a few examples of the 
consequences and shortfalls in accessibility and the 
disproportionate impact that is the result.
    A Florida man with quadriplegia using a power wheelchair, 
separated from his fiancee and was sent to a special needs 
shelter, then discharged without any assistance or plan other 
than to return to his destroyed dwelling. He had to sleep 
outside for several nights until the temperature caused him to 
have heat stroke. In partnership with the FEMA Disability 
Integration Advisor, we have assisted him to obtain temporary 
sheltering in a wheelchair-accessible hotel room.
    A woman called from a nursing home she had been transferred 
to after evacuating from Houston to Dallas. She told us the 
nursing home wanted her to sign over her Social Security and 
FEMA benefits, which would make leaving the nursing home 
impossible. We have connected her with legal assistance to 
protect her rights and address her need to return to Houston as 
soon as housing can be found.
    Many older adults and people with disabilities in 
highrises, trailer parks, and other locations have been 
disconnected from response and relief resources, and still are, 
and have had no food, water, or power. Our community-based 
partnerships have been their saving grace time and again.
    In my written testimony submitted for the record, I have 
enumerated a short list of recommendations and impactful 
actions to improve our national approach to whole community 
inclusive emergency preparedness and disaster response. In 
summary, we are calling for the establishment of a national 
commission on disability and aging emergency preparedness and 
disaster management to take the many lessons observed and turn 
them into whole community inclusive actions.
    For the 59 million Americans with disabilities, including 
over two million in nursing homes, and the 67 million Americans 
over age 60, providing equal access to emergency services and 
programs is not just the right thing to do or simply smart 
business practice; it is also a legal obligation. People with 
disabilities have a legal right to equal access and 
nondiscrimination. Our civil rights are not waiverable. There 
is no disaster loophole that allows for the suspension of our 
civil rights. Ensuring the federally mandated civil rights of 
people with disabilities will well serve everyone with access 
and functional needs. A national commission on disability and 
aging emergency preparedness and disaster management will serve 
to leverage the priceless expertise of those of us most 
impacted and will manifest the mantra of the disability rights 
movement which applies to everyone with access and functional 
needs. Nothing about us without us.
    Thank you.
    The Chairman. Thank you very much, Mr. Timmons.
    Chief Delaney.

 STATEMENT OF JAY DELANEY, FIRE CHIEF AND EMERGENCY MANAGEMENT 
 COORDINATOR, CITY OF WILKES-BARRE, WILKES-BARRE, PENNSYLVANIA

    Mr. Delaney. Good morning, Chairman Collins, Ranking Member 
Casey, and members of the U.S. Senate Special Committee on 
Aging. Thank you for inviting me here today to discuss how 
cities and towns across the country can help ensure the health, 
safety, and resilience of older Americans and individuals with 
disabilities during and after disasters.
    I am the fire chief for the city of Wilkes-Barre, 
Pennsylvania. I have been honored to serve the city in this 
role for over 12 years and have a total of 36 years in 
emergency services. I am also the emergency management 
coordinator for the city of Wilkes-Barre and a certified 
paramedic.
    Over 40,000 people reside in Wilkes-Barre, a city located 
in Luzerne County. Nineteen percent of the county's residents 
are over 65, which is 3 percent higher than the average in the 
State. And many of the older residents are concentrated within 
the city limits.
    Like any fire chief or emergency management coordinator, I 
feel a great sense of responsibility for these older 
Pennsylvanians, many who live by themselves.
    My concern for their well-being is heightened whenever 
there is a threat of a severe storm or weather event. That is 
due to a 10,000-square-mile watershed that drains into Wilkes-
Barre from the Susquehanna River, threatening to flood our 
streets and our neighborhoods.
    In 2011, the threat became very real as the east coast 
braced for Hurricane Irene and Lee to make landfall. What 
transpired over the next week explains why early weather 
tracking, data, surveillance, and the flow of information 
across all levels of government is a priority and critical to 
the health and safety of our residents.
    About 7 days before the storms were scheduled to hit, we 
heard from the National Weather Service, Mr. Dave Nicosia. They 
started to send us regular updates about the storm patterns and 
the possible rainfall and potential crests of the Susquehanna 
River. The Pennsylvania Emergency Management Agency 
disseminated critical data to the county emergency management 
officials and the emergency management coordinators for our 
municipality.
    Wilkes-Barre is protected by a U.S. Army Corps of Engineers 
levee to a river level of approximately 42 feet. The 
Susquehanna River crested on September 9, 2011, at a record and 
historic level of 42.66 feet.
    For years, the gauges that measured the water height of the 
Susquehanna River in Wilkes-Barre were broken, and they were 
the responsibility of the U.S. Geological Survey.
    Senator Casey led the charge here in Washington to secure 
the resources to replace our broken gauges. It is because of 
Senator Casey that we can track, in real time, the possibility 
of a flood and critical river level data. This type of 
surveillance information provided the needed data to make risk-
based decisions for possible evacuation.
    Using maps of flooding that took place in 1972 after 
Hurricane Agnes, we created an evacuation zone. And on 
September 9, 2011, we successfully evacuated 15,000 residents 
of Wilkes-Barre in about 10 hours. This evacuation included 
Wilkes-Barre City Hall, Wilkes-Barre Police Headquarters, 
Wilkes-Barre Fire Headquarters, as well as the entire downtown, 
including King's College and Wilkes University.
    We alerted the local hospital and two nursing homes in the 
evacuation zone. They executed their Emergency Preparedness 
Plans and safely evacuated 250 seniors. And if at any time they 
thought they were going to have trouble evacuating in the time 
required, they knew to request additional help from the Wilkes-
Barre City Emergency Operations Center. We would send 
ambulances and personnel to help if needed.
    But it was the older Pennsylvanians, the seniors, and those 
with disabilities who still lived in their homes and in the 
community that I worried most about--the Mr. and Mrs. Smiths, 
the Mr. and Mrs. Joneses, who have lived in their homes for 50 
years.
    In preparation for a possible evacuation, we developed a 
grid designating areas of responsibility for the Fire 
Department, for the Police Department, and members of the 
National Guard.
    We drove through South Wilkes-Barre and the downtown making 
announcements from our vehicles, knocking on doors, and posting 
evacuation orders. We knocked on every door. We left notes on 
doors of the homes where no one answered and made an additional 
check to ensure their evacuation. Most people heeded the 
request to evacuate on the first try, but if anyone resisted, 
they took their names, wrote down the addresses, and we spent 
additional time working to get them out of their homes.
    We successfully executed our plan because of the seamless 
collaboration and communication among officials at the 
national, state, and local levels.
    But even so, after every major event, we look back and 
discuss how can we improve. For example, should we ever need to 
evacuate again, we now have a contact in place with a local bus 
company that agreed to drive routes throughout the city to pick 
up people and take them to safety.
    Following Hurricanes Harvey and Irma, I hope that Congress 
will conduct its own after action review as it did after 
Hurricane Katrina in August of 2005. While Presidential 
Directive 5 started the advancement of the National Incident 
Management System, it was for the most part put into action 
after Hurricane Katrina and is now the model for how all levels 
of government manage all types of emergencies and disasters. As 
part of that review, I hope that Congress will commit to 
continue to fully fund the National Weather Service and FEMA 
and invest in surveillance tools so that we have the most 
comprehensive information available before, during, and after a 
disaster to guide our decisionmaking. Without early weather 
surveillance, we have little time to plan and prepare for 
potential weather events.
    I am grateful to the Senate Special Committee on Aging for 
the opportunity to add my voice to this conversation here 
today, and I thank you.
    The Chairman. Thank you very much, Chief, and thank you for 
reminding us that while our neighbors to the south tend to be 
disproportionately affected by weather disasters, we who live 
in the Northeast are not immune either. How well I remember the 
historic ice storm of 1998--I had been in the Senate for a 
year--which left so many of my constituents without power for 
so long and required the opening of emergency shelters through 
much of the State. So the point is it can happen anywhere, and 
all of us need to be prepared. So thank you for recounting your 
experience as well.
    Dr. DeSalvo, I was very interested in learning about the 
emPOWER program, which you have been so instrumental in setting 
up and sharing with other states. Obviously, electrical power 
is key. It is key whether we are talking about air conditioning 
in Florida or we are talking about keeping warm in Maine.
    What other gaps do you see that seniors and disabled 
citizens need?
    Dr. DeSalvo. Senator, a tool like emPOWER that uses medical 
claims data gives us a sense of people's health on a population 
level, so it can identify not only people who are electricity 
dependent but also people who are on dialysis, individuals who 
have ambulatory challenges, may be wheelchair bound, as an 
example. And in New Orleans, when I was health commissioner--
and we still use it regularly--it is a way, for example, if 
there is a boil water advisory, that we are able to target 
individuals who might be on special feedings or on dialysis, 
and we want to forewarn them in advance of water issues. So it 
is not just for electricity.
    But, on the other hand, it has to be used, and I cannot 
emphasize that enough. Just because we want to try to make the 
evidence-based decisions and we want to use data in respectful 
ways to identify people at risk, there have to be humans on the 
other end that can take that information and make use of it by 
making phone calls, by going to people's doors. But really the 
opportunity is pretty great not only in big disasters but in 
the smaller ones that communities face every day to try to 
target limited resources to reach those who have the highest 
risk.
    The Chairman. Thank you.
    Dr. Hyer, you gave an excellent explanation of the dilemma 
that many long-term care facility administrators face when 
deciding whether or not to evacuate, and I remember reading of 
the controversy over the mayor of Houston's decision to not 
order an evacuation; and yet in other cases where evacuations 
have been ordered, more people died in automobile accidents 
trying to get out of the area. And I can see you are nodding in 
agreement, so I am saying that for our court reporter here. So 
the act of evacuation, while totally appropriate, in many cases 
can actually be more dangerous than sheltering in place. And 
you talked about what is needed, however, for people to safely 
shelter in place. We have also talked about seniors who simply 
may be very fearful or unable to evacuate.
    So give us a little more guidance on how you would advise 
public officials or nursing home administrators to make the 
critical decision between sheltering in place and evacuation?
    Dr. Hyer. Thank you, Senator Collins. Yes, with Rita, there 
were 22 people who were killed in that bus as they evacuated.
    I think it is a very complicated but critical question. The 
emergency management people that I work with say ''you run from 
the water''. If you expect that there will be high levels of 
water and you cannot maintain safe care of residents, then you 
should leave. But those emergency managers ask if ``you can 
hide from the wind''. I think we need to think about having 
buildings built in places that are appropriate and can sustain 
usual low level disasters. I am not sure that nursing homes 
should stay, if a Category 5 hurricane is coming in directly at 
them. It is just devastating.
    However, I think for the most part, many buildings can, in 
fact, shelter in place appropriately. In countries--in Taiwan, 
they build water gates, and that is exactly what they did in 
Houston. And people will evacuate up onto higher floors. You 
can stay within the building, but be sheltered on a different 
floor. Now, that requires a lot of planning and a lot of 
forethought. It also requires you to make sure that you have in 
place the necessary equipment and food and water. Those are 
usually in place for nursing homes. Those regulations have been 
in existence for a long time. But one of my colleagues in 
Florida always says you shelter in place until you cannot 
shelter in place. Things happen after storms. There were 40 
evacuations in Florida of nursing homes after Irma. Some of 
those were because trees fall, things happen, winds rip open 
roofs, and the place is not safe, it becomes inhabitable. Those 
evacuations are appropriate.
    But many of those evacuations occurred because power was 
not restored, because there were not generators, or the 
generators were not appropriately built in a way that they can 
sustain residents. There was not enough fuel.
    Those regulations have been changed by CMS for nursing 
homes, not for assisted livings. I do not even know if assisted 
livings in Florida are required to have generators. Assisted 
livings really are under the radar.
    So I think the answer is that you want to be able to have 
people stay in the building, but the building has to be 
hardened. They cannot be built in flood areas that routinely, 
in heavy storms, continue to flood. And there are building 
codes that allow that to occur.
    We also need to have them hardened and have generator 
capacity. Some buildings are very old. Many nursing homes in 
this country are very old. And I think we need to think about 
if we are going to allow capital to be used to replenish them 
or if we have got certificate of needs, replacing some of them, 
I think we need the new buildings to require generators with 
sufficient capacity to run air conditioning and other support 
systems for a period of time. And 96 hours is what hospitals 
are required to have.
    The Chairman. Thank you very much.
    Senator Casey?
    Senator Casey. Thanks very much. I will start with Chief 
Delaney.
    Chief, first of all, thanks for being here and thanks for 
your testimony and your continued leadership doing a tough job. 
We are grateful for that.
    I have a good recollection of what we all saw in 2011 in 
your home county, Luzerne County. I cannot remember how many 
counties I went to, but we had northeastern, central, and 
southeastern Pennsylvania, almost virtually half the State, 
affected by--and I want to use the right terminology. Irene was 
a hurricane, Lee was a tropical storm, I think technically, 
but----
    Mr. Delaney. They were both bad.
    Senator Casey. The combination was terrible. And for me, it 
was an eye opener because I had never been affected personally 
by a terrible storm or a flood. And even as a public official, 
I am not sure I had ever been as close to it as I was in 2011 
when we would be walking through those communities in most 
cases a few days after, I guess in some maybe only hours. But 
what I learned from that is just how violating that is or how 
devastating that is in a very personal, even emotional way.
    I remember a friend of mine who was kind of the ultimate 
tough guy, never bothered by anything, always confident, even 
cocky about everything. I walked up to him--his house had been 
flooded, and I walked up to him and said, ``How is it going?'' 
He just dissolved in tears. This really tough, tough guy just 
was absolutely devastated. So that gave me an insight, I guess, 
into the horror of it, and what we saw in Texas and Florida and 
we are seeing all these days in all these other places is maybe 
even worse than I saw in 2011.
    So one point that you made was the importance of good data 
and to informed decision making. We worked together, as you 
mentioned, on the stream gauges and helping to gather 
information. Talk to us about what data you use to inform your 
decision making when you have got an emergency, in this case an 
impending hurricane. What data do you use?
    Mr. Delaney. This is not really hard. We start with the 
critical data, hydrological data from the National Weather 
Service. That is why I say that agency is critical for the 
information that they send to PEMA, the Pennsylvania Emergency 
Management Agency, down to the Luzerne County Emergency 
Management Agency, and that flow of data to us. They have some 
of the best scientists available that can predict what the 
rainfall will be, what the river cresting will be, and that 
data we use for risk-based analysis to decide whether we are 
going to evacuate or not. And as you know, the river gauge that 
did not work almost crippled us where we did not know what the 
river was doing.
    So I think from an emergency management standpoint, we can 
prepare for a lot of these disasters because we have some of 
the best scientists in the world that can predict what is going 
to happen. So we take that data. We make sure we have our 
emergency operations plans. We make sure we write a plan with 
our municipal officials. In particular, for Lee and Irene, 
Luzerne County opened their Emergency Operations Center early 
on because of this prediction, which set the National Guard 
there in place so that if we needed to evacuate, that tool was 
already there to help us.
    So I think a lot of the surveillance data is critical for 
that flow of information to come down, number one. And, number 
two, the National Incident Management System and unified 
command is used to make decisions. So I am the emergency 
management coordinator, but I have a boss, and he is the mayor. 
And we have a city administrator; we have department heads. In 
emergency management, one person does not make the calls. You 
talked about sheltering in place. We had a small fire in a 
nursing home in Wilkes-Barre two weeks ago, and we decided--it 
was only a really small fire--to shelter in place. We probably 
had ten decisionmakers there to help make the decision on what 
the best well-being would be for the 166 residents that lived 
in that place.
    So we have systems in place. We really need to use them and 
use them adequately.
    Senator Casey. I know I am almost out of time. I was going 
to ask you as well about sometimes we think of, as you point 
out, response tools being things, equipment, whether it is to 
remove downed trees--but the challenge you have is having 
enough personnel, enough manpower, human capacity, human 
infrastructure to be able to go door to door. Talk to us about 
that.
    Mr. Delaney. Sure. On a daily level, you know, we have 12 
to 14 firefighters and paramedics working and maybe the same 
amount of police. But by getting this surveillance information 
data, we can go to our bosses, our elected officials, and say, 
``Listen, we need to prepare. We need to have all 80 
firefighters at work for the next 3 days.'' We did that during 
the disaster--I should say the winter weather event, the 
blizzard we had in northeastern Pennsylvania this past year, we 
utilized that.
    So, you know, to make these decisions, that information 
early on, and I always have to put my request in for AFG and 
SAFER, the Federal programs that help us to have the proper 
staffing. My department does about 11,000 calls a year. We are 
set up for all hazards. But we deliver babies, we put fires 
out, we rescue people from the river, we take care of hazmat 
incidents, we take the tree branches--we do all those things. 
So, yeah, staffing is critical. This early information early on 
helps us to have the right amount of people to handle the 
event.
    Senator Casey. Thanks, Chief.
    The Chairman. Thank you very much.
    Senator Cortez Masto?
    Senator Cortez Masto. Thank you. First of all, let me just 
say thank you to Chairwoman Collins and Ranking Member Casey 
and all of you here. It is such an important topic, and I so 
appreciate the conversation this morning.
    I had the opportunity to work in state and local government 
in the State of Nevada, and I think people do not realize how 
important emergency management at the local, state and federal 
level is. And people are working every day so hard to get it 
right. God forbid something should happen, but they want to 
make sure they get it right. And many times the emergency 
management services are underfunded or they are challenged, and 
they need more support.
    I have a couple of questions, because it came to my 
attention that the Department of Housing and Urban Development 
recommends, but does not require, that public housing 
authorities establish emergency preparedness and response 
plans. I am curious if you are aware of this, and/or in your 
own communities, how have you brought in some of those 
vulnerable populations that live in some of the housing that is 
established through HUD?
    Dr. DeSalvo. Senator, I want to take this opportunity to 
thank you for raising the issue of HUD and housing because it 
is a great reminder to us that emergency response is more than 
people in uniforms with lights and sirens and even public 
health and health care officials, that there are a lot of 
people who have roles to play in a lot of agencies. And housing 
in particular, I think what you have heard thematically here is 
that that is a place where we can do a lot of good if we 
prepare properly and think about building code and building 
preparation, whether that is elevating generators or thinking 
about having exit lighting that is available as part of the 
generator.
    In addition, though, what HUD has access to is a lot of 
information about people who live in the housing, and so better 
communication and coordination of what they know about the 
disabilities or the special needs of people in housing could be 
of great benefit to the people who are on the front lines, and 
also in between, building resiliency, making sure that people 
have the kinds of supports so they can individually be 
prepared.
    I just want to point to an example more recently where HUD, 
I think, leaned in quite well, and that is in Flint, Michigan, 
where when we were trying to understand how to reach kids and 
families to let them know about opportunities to get screened 
and treated for lead poisoning, that the HUD agencies locally 
were able to get their databases and know where there were kids 
and helped direct resources. So I have seen it in action in a 
slower-burn emergency, but I think there is a lot of 
opportunity at the federal, state, and local level to better 
coordinate the information and the resources.
    Senator Cortez Masto. And I appreciate that because I think 
just like your interaction in gathering the data and working 
with Medicare to identify a population, HUD can do the same 
thing. Federal agencies have access to this data that can help 
emergency management at the state and local level as well, and 
I think there needs to be more of that partnership.
    And so that is why, Mr. Timmons, when you talked about 
needing and recommending a national commission--can you talk a 
little bit more about that? And is that your thought, that 
there is more of that interaction and that sharing of data and 
information with the state and local emergency management 
systems?
    Mr. Timmons. That is exactly right, Senator. In my mind, 
this comes down to planning, and I differentiate between plans 
and planning, much as General Eisenhower did. Plans are 
worthless. Planning is invaluable. It is not a matter of just 
creating a plan and hitting the print button. I think we need 
to be in a perpetual state of planning, and some sort of 
national infrastructure to facilitate that I think is critical 
to give us consistency and to help us leverage.
    The aging and disability stakeholder organizations need to 
be involved in this process from the beginning. We are the 
experts on what we need, and we are the experts on how to 
negotiate getting that in the most efficient fashion.
    I would like to see each state have an access and 
functional need coordinator within its emergency management 
function. We have a couple of models of that in Mississippi and 
California, notably, and it is making a tremendous difference.
    At the end of the day, I believe this is a relationship 
thing. Where we see this work is where there are preexisting 
relationships between emergency managers and stakeholder 
organizations. Where we see it not work so well is where there 
are not, and I do not think it is coincidental.
    So what I am suggesting is creating some sort of a 
framework to do this in an efficient and effective and 
impactful manner. Thank you.
    Senator Cortez Masto. Thank you. I notice my time is up. 
Thank you so much for the conversation and the work that you do 
every day.
    The Chairman. Thank you so much.
    I am going to follow up on the questions that my colleague 
just asked. Chief Delaney, let me start with you, and you had 
talked about emergency preparedness must start with the 
communities. What are some ways beyond looking at HUD data, 
which I thought was an excellent idea, that we can involve 
organizations--I can think of Meals on Wheels, Area Agencies on 
Aging--that have regular contact with seniors in our 
communities and would be aware of who would need help or whose 
housing might not withstand the blow of a hurricane or an ice 
storm or a flood? Are they involved at your level with the 
emergency preparedness planning that you do?
    Mr. Delaney. Well, there is a lot of individual programs 
that are out there, but, again, how do we engage Mr. and Mrs. 
Jones, Mr. and Mrs. Smith, who have lived in their house for 50 
years? That is a tough nut to crack because when you have to 
evacuate 15,000 people in 10 hours, you do not really have the 
time to sit and say, ``Well, here is why you have to go, 
ma'am,'' or, ``Here is why you have to go, sir.'' That is a 
difficult question. If we could get that answered, I would 
think we were well on our way.
    But I did want to address the assisted living facilities 
and nursing home facilities. That is critical that they have 
their plans and their plans address how to get out, because 
when we evacuated in 2011, we trusted their judgment. We said, 
``You have 10 hours to evacuate your facility.'' In their 
plans, they have strike forces of ambulances. They have all the 
critical data needed to get out. So I think mandating these 
plans is critical. I just received a 40 page document the other 
day. It seems as though we are getting better at getting these 
plans, but there needs to be a regulatory agency to say you 
have to have this plan. The local officials need to get this 
plan so that we are aware of what is in their plan.
    But, Senator, to address you, I think that is a great 
discussion to have. The organized facilities have--they know 
what to do. It is the average citizen that kind of does not 
understand it. They have not talked to folks for days or weeks 
about anything potential that might go on. So it takes a long 
time. And when we need to get them out, we do not have the 
luxury of all that time. So that is a great conversation to 
have, I think.
    The Chairman. Thank you.
    Mr. Timmons, I really appreciate your reminding us that 
this conversation on emergency preparedness needs to go beyond 
seniors and also focus on individuals with disabilities. What 
is your assessment of the level of emergency preparedness in 
terms of meeting the needs of people with special needs? Do 
they have shelters that are equipped to take care of people 
with disabilities? Are they staffed with people who will 
understand what they need? This is an area that I do not think 
has received as much attention, so I would love to have you 
elaborate on it?
    Mr. Timmons. So, particularly with the Red Cross, we have 
made some progress in the last couple of years in terms of 
trying to create an infrastructure, with them working with the 
community and with our stakeholder organizations and aging 
stakeholder organizations so that all shelters are accessible. 
I would again reiterate that in my mind this is a civil rights 
issue. So the Red Cross is the primary shelter operator across 
the country, and we have seen a tremendous amount of progress 
from them in terms of being ready and engaging in planning and 
engaging in exercising. And so in a number of places, we are 
seeing a tremendous difference. They are sort of the industry 
leader in this, and it is my hope that in areas where perhaps 
they do not operate the shelters, those who are will learn some 
lessons from that.
    So we are making incremental gains. It is a slow haul. But 
we are beginning to see some understanding, I think, from the 
folks in the shelter business that this is a civil rights 
issue, that it makes economic sense to make all of the 
sheltering and all of the servicing accessible to everyone. It 
is a legal obligation. It just makes sense. It is a great 
business case. So we are making progress, Senator.
    The Chairman. Great. Thank you.
    Senator Casey?
    Senator Casey. Thanks.
    Dr. DeSalvo, I wanted to ask you about a related topic. We 
are in the midst of yet another health care debate, and even in 
the midst of that, we have had some good bipartisan work on 
health care the last number of weeks, more than two weeks now. 
In your testimony you made clear that you have seen in real 
time, both in your clinical practice and as a public health 
leader, the devastation that a hurricane can cause to seniors 
with chronic conditions, as well as individuals with 
disabilities and others. So given that experience, how 
concerned are you about the latest health care bill that the 
Senate is considering?
    Dr. DeSalvo. Well, Senator, Louisiana in 2005 was a state 
with the unhealthiest population in the country and some of the 
highest rates of uninsurance, and access to care for low-income 
and high-need people, largely emergency rooms, which prevented 
them from having relationships in primary care, so people who 
knew about their health and could reach out to them in between 
disasters. When they were evacuated, it meant that they arrived 
sometimes in other states without any way to get care because 
they did not have a way to pay for it, and the absence of 
having public or private insurance and having relied in our 
state on the charity hospital system. And I will tell you, 
someone who has been in Louisiana for decades and have been 
telling my colleagues about what it was like to practice in an 
environment where your patients were uninsured and you sent 
them out sometimes on a hope and a prayer that they were going 
to be able to get that colonoscopy or get the medications that 
they needed, it was really shocking to my colleagues in other 
states that were on the receiving end of these individuals who 
had so much medical need and in many cases social need and not 
a means to pay for it when they arrived in a new state. And I 
think it spotlighted for certainly us in Louisiana but our 
colleagues around the country that having a great institution 
or place is not the only solution to access to care. You have 
got to have an affordable way to pay for your care, not only in 
disaster but every day.
    So far in Louisiana in the last decade, with the recent 
expansion of Medicaid, actually the opportunity for us is less 
focused on what is going to happen to those folks who are 
uninsured or who maybe do not have the means, than how can we 
make the system really work better for them. And I would not 
want us to take a step back, not only in Louisiana but as a 
country.
    And, Senator, if I could, I just might mention the sort of 
additional piece that has been raised because it is also part 
of the thinking of how to--what may happen in this bill, which 
has cuts to the prevention fund, which supports public health 
across the country. And public health, an unsung hero in 
disaster and every day, literally saves your life every day. It 
makes sure you can drink water safely and eat food and be 
rescued in the event of a disaster. But it is struggling 
already, much less having additional cuts. And it is so 
pertinent to this threat of conversation about people with 
disability, people who have special needs, because you do not 
want to, as in my case, learn about that in the middle of a 
disaster. As I showed you in Isaac, you want to know about 
those folks well in advance, and you need to be able to 
leverage local community organizations who have connections to 
those individuals, whether it is Meals on Wheels or the faith-
based community. That kind of coordination and communication 
and relationships does not happen just by happenstance. It 
requires work and it requires resources, human resources, time 
resources, and that requires financial resources to make sure 
that local communities have the bandwidth in time to work 
together. So I hope that we will not step back, but continue to 
step forward.
    Senator Casey. I appreciate that.
    Mr. Timmons, I wanted to ask you as well about among your 
recommendations is the idea of a federal task force or 
committee to coordinate efforts across not only Federal 
Government agencies but state and stakeholder groups as well. 
What are some of the advantages that communities would see if 
planning were better coordinated?
    Mr. Timmons. Thank you. In this way I would hope we could 
optimize our limited resources, reduce duplication of efforts 
that we see, again, create and nurture relationships because 
the time to do that is when the sky is blue, and so do that in 
a consistent and meaningful way, using people with access and 
functional needs as force multipliers rather than seeing us as 
liabilities. Planning perpetual vigorous planning and 
exercising is something that we would like to see consistently 
done around the country. Optimizing health, reducing the need 
for acute medical care in these situations I think would be a 
tangible result that makes business sense. Universal 
accessibility, ensuring the civil rights of people with 
disabilities affects the broader access and functional needs 
community. So doing this in a consistent, federally mandated, 
overarching way just makes sense.
    It has been said all disasters are local. There is truth to 
that, and in this way I think we could build up the local piece 
so that folks like the chief are serving their community and 
that people are working together to achieve the goals we are 
all after. Thank you.
    Senator Casey. Thanks very much.
    The Chairman. Thank you.
    Senator Cortez Masto?
    Senator Cortez Masto. Thank you.
    In Nevada, and I am sure in many of your States, we have 
rural communities that are challenged--forget just getting 
resources there--professionals, you name it, it is--and 
geographically challenged. Some of our rural communities it 
takes four hours just to drive into, there are no planes, there 
is no bus service. And so I am curious how we support a state 
in a statewide effort to pull our rural communities into this 
emergency management preparedness and if you have any thoughts 
on that.
    Dr. DeSalvo. I will start, and maybe I will spark some 
additional conversation. I am really glad that you raised it, 
that when you map the challenges in rural communities, it will 
overlap with challenges in individuals' resources, access to 
transportation, all the things that make them more vulnerable 
to disaster. And also our experience in Louisiana is that it 
also is a challenge because those may be individuals less 
willing to relocate to shelters, particularly if they are 
living on the coast. For lots of reasons, cultural and 
otherwise, they want to shelter in place. And it is just a good 
reminder that there has to be coordination across 
jurisdictional lines.
    Our experience locally was that we had a regular cadence, a 
battle rhythm, where--a terrible term, but that is the exchange 
preparedness language of each of our local jurisdictions, in 
our case parishes, have their own preparedness conversations 
about their populations but scaling that across the day to make 
sure that we were thinking about regional and then statewide 
support and coordination, because this is the thing, and Isaac 
is a great example of this. We did not flood in New Orleans 
Parish in Hurricane Isaac. We had a power outage situation. But 
the parishes just next to us, the counties just next to us 
flooded. And so because we were hardened and ready from an 
acute-care standpoint and because we were communicating, we 
were also hardened and ready to take people from the 
surrounding parishes and stand up a medical special needs 
shelter to support people. And some of those are pretty rural 
environments on the coast. But without, again, those 
preexisting relationships when the skies are blue, the 
communication infrastructure and everyone knowing kind of what 
a sister relationship will look like, we are not really ready 
to help each other. And so though it is local, there has got to 
be coordination that scales to help bridge the gaps.
    Mr. Timmons. In some ways I think maybe the paradigm should 
be that we let the local communities draw us into the way they 
do this, Senator. There is a lot to be said about the power of 
community in some of our more rural areas. I live in South 
Carolina. We saw this two years ago with the flood, and we saw 
it last week as we experienced some of Irma. A lot of the 
things that I am talking about, the broader community 
engagement, the local nature of this, is done really well in 
our rural communities.
    There are some challenges, but there are also some lessons 
to be drawn from that that we can apply in other areas as well.
    Senator Cortez Masto. Thank you. Thank you very much.
    The Chairman. Thank you, Senator.
    I want to thank all of our witnesses for your testimony 
today and for the really important work that you are doing at 
the local, county, and state level, private sector, public 
sector, nonprofits. You are all making a difference on the 
front lines.
    I also want to thank our staff, which worked hard to bring 
this hearing together. We delayed the date of this hearing 
because we did not want to interfere with the immediate 
response that was occurring in Florida, for example, and in 
Texas, because I know from the medical team that helped out in 
both places that first responders from all over the country 
were assisting in the response, which is a real tribute to the 
first responder community.
    September is National Preparedness Month, and this year's 
theme is: ``Disasters do not plan ahead. You can.'' We should 
take that motto to heart, and from this hearing today I can see 
the huge amount of progress that has been made since I 
conducted that investigation so many years ago into the very 
inconsistent and in some ways failed response to Hurricane 
Katrina. So we have made great progress, but we still have a 
long ways to go.
    I love Dr. Hyer's list of exactly the four--I wrote them 
down, things that need to be done. I would note that Governor 
Scott has issued an order that says that assisted living 
facilities also have to have generators and fuel to supply 
them.
    So we are learning from every disaster, and we are learning 
how being prepared today can make the difference between safety 
and danger, and in many cases literally the difference between 
life and death. For older Americans and those with 
disabilities, there are ways to anticipate the unique 
challenges associated with aging, mobility impairments, and 
medical needs. For seniors living at home, for those in 
assisted living facilities, and for those in nursing homes, 
there are ways to prepare even though disasters can strike with 
little warning, and I think we have learned a lot today about 
the importance of communication, working together, and as Dr. 
DeSalvo notes, my favorite expression is to say that you should 
not be exchanging business cards when disaster strikes. That is 
the worst time. And you have to prepare in advance.
    I want to close my remarks by also warning the residents 
who have been affected by these storms of the many scams that 
have already arisen. This Committee has held hearing after 
hearing on financial exploitation of our elderly. There are two 
scams in particular that seem to be very prevalent.
    One is what I would call the charity scam where people are 
trying to get donations that purportedly are going to the 
victims of the hurricanes but, in fact, are lining their own 
pockets. So I would urge people to deal with recognized 
charities, to be very careful. And I know the former Presidents 
have come together to encourage donations. You can be sure that 
is a safe one. But that is a scam that is relentless and 
heartless.
    And the other one is an old scam that occurs every time 
there is a disaster like that, and that is when people are 
pretending to be qualified to repair homes to make them 
habitable again and ask for an up-front payment and then they 
will do the work. And, of course, they disappear with that up-
front payment and are never heard from again.
    So my heart goes out to people who have been affected by 
the storms, but I also want to give them a caution to be very 
wary of people who would exploit the suffering of others and 
the devastation of these storms in order to line their own 
pockets. And I just wanted to mention that this Committee will 
put out a bipartisan alert to try to raise awareness among the 
victims of the storms.
    Again, thank you to all of our witnesses, to all of our 
members who are here today, and Committee members will have 
until Friday, September 29th, to submit any additional 
questions for the record.
    I should say that both of the Senators from Florida, who 
are on this Committee, really wanted to be here today, but they 
rushed back to their home state as soon as they possibly could 
to help out. And that is certainly understandable as well.
    Senator Casey, do you have any closing comments you would 
like to make?
    Senator Casey. I do. Madam Chair, thank you very much, and 
thanks for calling this hearing.
    Dr. DeSalvo, Dr. Hyer, Mr. Timmons, and Chief Delaney, we 
are all grateful that you are here today and giving this 
testimony, bringing real expertise and experience to these 
issues. A special thanks to Chief Delaney. We live in the same 
home area, one county away, and we are grateful you made the 
trip down from Pennsylvania.
    I share Senator Collins' commitment to making sure that we 
are doing everything, everything within our power to ensure 
that seniors and people with disabilities are prioritized in 
emergency response in the midst of these horrific challenges. 
It should not take the deaths of Americans or the kind of 
photos that we saw to cause us to take action and to move this 
issue to the top of the agenda, including here in Washington. 
That is why we are grateful that we now have legislation that 
will begin to address some of these issues.
    We need to learn from these tragedies, and we need to 
commit ourselves to the goal that they will never happen again. 
So I look forward to continuing to work with members of this 
Committee on these issues, and we are grateful for this 
opportunity today.
    Thank you, Madam Chair.
    The Chairman. Thank you.
    Senator Cortez Masto, since you are such a dedicated member 
of this Committee, if you have any final words, feel free.
    Senator Cortez Masto. No, I am good. Thank you very much.
    The Chairman. Thank you. Thank you for your participation.
    This hearing is now adjourned.
    [Whereupon, at 10:34 a.m., the Committee was adjourned.]

      
      
      
      
      
      
      
      
      
      
      
      
      
      
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                                APPENDIX

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               Prepared Witness Statements and Questions 
                             for the Record

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      Prepared Statement of Karen B. DeSalvo, M.D., Former Health 
       Commissioner, City of New Orleans, New Orleans, Louisiana
    Good morning Chairman Collins, Ranking Member Casey and 
distinguished members of the Special Committee. Thank you for the 
opportunity to testify today to share my experiences and perspectives 
on opportunities to better support older Americans both in times of 
disaster and every day. I am Dr. Karen DeSalvo, a physician and former 
Health Commissioner for the city of New Orleans.
    I am honored to participate in this panel with my distinguished 
colleagues. Disaster Preparedness and Response for Older Americans is a 
topic about which I have great passion--both as a doctor and public 
health professional. Raising awareness of the challenges they face and 
opportunities to better support them is a critical conversation.
    Though there has been a great deal of progress in the last decade, 
more can be done. My goal is to share with you some of my experiences 
from New Orleans as a physician and as Health Commissioner and to offer 
solutions aimed at building a stronger infrastructure and support 
network to improve outcomes for some of the most vulnerable in our 
community--older Americans.
Experiences From the Front Lines
            Hurricane Katrina
    It is now a dozen years since Hurricane Katrina wrought devastation 
to my hometown of New Orleans. In New Orleans, though we escaped the 
direct impact, our catastrophe was failed flood walls, leading to 
inundation of our city with water for weeks and devastation of our 
entire health care and public health infrastructure. From 911 to major 
hospitals, access and capacity were submerged, along with Charity 
Hospital, the primary provider for the poor and uninsured in New 
Orleans.
    According to a report from the Louisiana Department of Health and 
Hospitals, 986 Louisiana residents died as a result of Hurricane 
Katrina. Older adults were disproportionately impacted: the mean age of 
victims was 69 years with 63% over the age of 65. Amongst the dead were 
70 people who died in nursing facilities either during the storm or in 
the days immediately following landfall.
    I was actively practicing medicine and most of my patients were 
older adults. It was a terrible feeling to know that my most vulnerable 
patients were disconnected from me, from their therapeutic regimens and 
care. At the time, like most of the country we were a paper-based 
health care system and those medical records turned to useless bricks. 
As people quickly evacuated or later landed in shelters or on rescue 
boats, they most often did not have their medicines or even a good list 
of them. This meant that essential information to guide clinicians 
trying to help displaced patients was not available. And those of us 
still in New Orleans did not have the capability to find our patients 
easily or to mine data to identify vulnerable patients in need of 
additional help.
    There were exceptions; Ochsner Health System and the Veterans 
Affairs health system were digitized and, as a result, able to provide 
more seamless care such as refilling medications for chronic disease or 
preventing gaps in cancer care. The contrast was stark and a great 
motivator to us in the health care system to make a transformational 
change that would link everyone to a medical home. By digitizing the 
health care records, we could have a health system more resilient for 
disaster and for every day. This shift would be particularly critical 
for older Americans who tend to have a higher burden of significant 
medical problems and more complex medication regimens.
    New Orleans, like the rest of the Nation, has transformed and now 
has a digital health care infrastructure that is increasingly 
connected. It also includes patient portals so that people can view 
their records to find up-to-date medication lists and medical 
histories. This infrastructure was used during Hurricane Harvey in 
Houston shelters to access health information in a way we only dreamed 
about 12 years ago during Katrina.
            Hurricane Isaac
    Six years after Hurricane Katrina, I had begun my service as Health 
Commissioner for the city of New Orleans. It was during my tenure, in 
August 2012, that Hurricane Isaac roared ashore in Louisiana some 7 
years to the day that Hurricane Katrina had landed. Fortunately, New 
Orleans, like much of the country had heeded the lessons learned in the 
health care and public health system. We were better prepared. Words 
from Senator Collins at the time of Katrina were a rallying cry for me: 
`` . . . the last time officials should be exchanging business cards is 
in the midst of a crisis.'' My efforts as a physician, advocate and now 
public official focused on building a more connected system to support 
those in need in the wake of disaster. In the intervening years, 
Louisiana and the New Orleans community had developed more targeted 
emergency and disaster preparedness planning for older residents and 
those with special needs such as those in nursing home settings.
    One of these actions by the New Orleans Health Department was the 
creation of a medical special needs registry to maintain a list of 
those most in need of assistance for evacuation during preparations or 
in response operations. We had been working aggressively to shift from 
paper to an electronic, searchable version. By 2012, we had improved 
our registry of high-risk individuals with special medical needs and 
had tripled the number of residents enrolled.
    In advance of the storm's landfall, we reached out to these high-
risk individuals directly and through social and traditional media to 
offer opportunities for evacuation, providing transportation for those 
who wanted to leave. We worked with the dialysis network to ensure that 
people accessed dialysis early and we coordinated with newly developed 
medical homes to see that people received supports, including adequate 
supplies of medications to carry them through potential disruptions of 
pharmacies.
    In the end, Hurricane Isaac did not flood New Orleans proper. 
Rather, the challenge New Orleans faced was prolonged power outage. 
Hurricane Isaac was a particularly problematic storm for power outage 
because it had a large wind field, which remained strong for days. This 
prevented repair crews from assessing outages and restoring power. More 
than 900,000 customers in Louisiana lost power representing half of the 
population. 400,000 were still without power September 1st, four days 
after landfall.
    The health care system fared well because of improvements in 
emergency preparedness made following Katrina. Though some hospitals 
lost power early in the storm, their back-up generators functioned as 
expected and maintained operations at facilities with very few 
exceptions. We were also watching the nursing homes carefully, and 
fortunately they reported working generators at their facilities as 
well.
    As the days dragged on, I found myself standing in the Emergency 
Operations Center being asked by our power company to give them 
guidance on the prioritizing power restoration. Hospitals were already 
on the priority power restoration list and returned to normal function 
for their inpatient and outpatient services. The question at hand was 
how to prioritize the remainder of our facilities and neighborhoods.
    The situation was further complicated by reports that seniors were 
struggling with the heat. For a variety of reasons, many high-risk 
individuals had not evacuated, despite our efforts to assist those in 
independent living situations. This included those in nursing homes and 
assisted living, but also people living in subsidized, high-rise 
housing around the city.
    Without information on where individuals with the most risk were 
clustered, we were compelled to go door to door for 3 days to try to 
assess need and help prioritize power service restoration. For those 
who would, we evacuated them to a newly established medical special 
needs shelter in the city.
            Leveraging Data and Technology
    Following Hurricane Isaac, we worked with the HHS Assistant 
Secretary for Preparedness and Response to create more efficient and 
effective methods of identifying the most vulnerable in our community, 
not only to target power restoration, but also to support them in other 
hazards as well. We needed an approach that could scale to support the 
approximately 2.5 million Medicare beneficiaries who are electricity-
dependent for medical and assistive equipment.
    In June 2013, HHS and the city of New Orleans piloted a first-in-
the-nation emergency preparedness drill. Using Medicare claims data we 
identified individuals with electricity-dependent durable medical 
equipment and securely disclosed it to a local health department. Along 
with first responders (particularly the fire department), we visited 
the homes of people identified on the list from CMS as being 
electricity-dependent. We wanted to know if Medicare claims data was 
accurate in identifying individuals using a home oxygen concentrator or 
ventilator. It was 93% accurate. In addition, of the 611 people that 
the claims data had identified in the New Orleans community, only 15 
were on our medical special needs registry. The drill findings 
reinforced our hope that medical claims data could be useful in 
improving preparedness and response for high-risk populations.
    This effort, now called emPOWER, has been scaled by HHS and is 
available to help first responders in planning and response. Every 
community can use the map to find the total of Medicare beneficiaries 
with electricity-dependent equipment claims at the U.S. state, 
territory, county, and zip code level. ``Real-time'' natural hazard and 
NOAA severe weather tracking services identify areas that may be 
impacted by disaster events and by prolonged power outages.
    HHS continues to deploy emPOWER to support communities in disaster 
including in the recent hurricanes Harvey and Irma, as well as for 
other emergencies ranging from boil water advisories to tornadoes.
            Beyond the Headline Disasters
    It is easy to focus on the national disasters that make headlines 
and on those who seem most frail such as those living in nursing homes. 
There is indeed work that needs to be done to ensure their safety in 
major events. The added expectations in the Centers for Medicare and 
Medicaid Services (CMS) Emergency Preparedness Rule are steps in the 
right direction. If robustly implemented by the providers, they could 
provide further protections for seniors.
    Those older Americans who are not in CMS regulated institutions, 
but rather are in community-based settings, living independently are 
also at significant risk. These older Americans need our help not only 
in disaster but every day. They are exactly the people who wanted to 
``shelter in place'' for Hurricane Isaac and likely every other major 
event. They want to stay in their homes and will resist evacuation to a 
shelter, including one with medical personnel. These are the people 
that we should focus on as we work to make the next order improvements 
to our disaster preparedness and response plans.
    These are the bulk of the people that I saw as I went door to door 
after Hurricane Isaac. Many are in federally subsidized housing, living 
alone or with other debilitated peers. What I saw was heart breaking. 
For many, they were trapped on higher floors, unable to navigate the 
stairs to escape when the elevators stopped working because they were 
wheel chair bound, dependent on a walker or simply not strong enough. 
What was clear was that they were not only isolated because of a 
hurricane, but were living on the edge every day. Any small disaster 
can easily cause them to decompensate.
    Leveraging tools like emPOWER to build more complete Medical 
Special Needs Registries is a start. But they also need ``human touch'' 
on an ongoing basis to help build their resiliency to withstand 
disasters large and small. The evidence is clear that older Americans 
are more likely to be lonely and socially isolated and those 
circumstances are associated with increased risk of medical 
complications and death. Efforts underway by national groups such as 
AARP's Connect2Affect to address social isolation are an important 
start, but these programs should also help link seniors with emergency 
preparedness personnel and programs.
Opportunities to Strengthen Preparedness and Response
    Though we have made progress, we must do everything we can to 
protect the most vulnerable in our communities, with special attention 
to older Americans. It is in that vein, that I offer actions that would 
build a stronger infrastructure and support network to improve outcomes 
for some of the most vulnerable in our community--older Americans.
            Leverage Data and Technology
    The reach of a tool like emPOWER should be expanded to a broader 
group of at risk individuals using data from Medicaid and private 
payers. In addition, technology tools like emPOWER are only helpful if 
the local officials are aware of the resource and able to use it. 
Congress could provide resources to support training exercises by the 
Public Health Service Commission Corps to test the use of emPOWER in 
communities across the Nation and help prepare the Public Health 
Service Commission Corps members to use the tool in disaster response.
    Older Americans will be best served when their health information 
is available when needed to inform care and evacuation decisions 
before, during and after disasters. The infrastructure is in place for 
this vision to be a reality but behavior in the health system is 
preventing technology from helping people when they need it most. Data 
blocking is one such behavior. Congress has already taken action to 
advance interoperability of electronic health records and other health 
data systems through the MACRA and 21st Century Cures legislation. In 
particular, expectations for providers to attest that they are not 
blocking data and the additional authorities for HHS are an important 
step to improve data flow on behalf of consumers. Congress should press 
the Administration to accelerate their timeline to develop educational, 
incentive based and punitive measures to address blocking. Furthermore, 
Congress should encourage the Office of the National Coordinator for 
Health Information Technology in partnership with the Assistant 
Secretary for Preparedness and Response to continue working with states 
and local communities on efforts aimed at leveraging electronic health 
record information for disaster preparedness and response. It is 
essential to quickly ensure private and secure data flow for existing 
health information given the opportunities on the horizon as new 
technologies like telehealth and wearable technology will be 
increasingly ubiquitous and able to support older Americans in 
preparedness and response.
            Support Local Public Health Infrastructure
    Local public health agencies are the only health entities with 
statutory responsibility to address preparedness and response. But they 
are under-resourced across the county, impairing their ability to 
support communities, including older Americans. The specific efforts 
that are often under-resourced include: Medical Reserve Corps, Medical 
Special Needs Registry, and preparedness staffing. Congress could ask 
the National Academy of Medicine to undertake a review of needs for 
local public health preparedness funding and make recommendations on 
approaches to addressing the gap.
    Congress should provide resources to support public and private 
sector programs that address loneliness and social isolation. The 
Medical Reserve Corps (MRC) is one such potential. It is a national 
network of volunteers, organized locally to improve the health and 
safety of their communities. The MRC volunteers include medical and 
public health professionals, as well as other community members who may 
not have a health care background. MRC volunteers are an essential tool 
to strengthen local public health and improve emergency response 
capabilities. They could also be an essential resource to build 
individual and community resilience between disasters.
            Protect Consumers
    The Centers for Medicare and Medicaid Services Emergency 
Preparedness Rule is an opportunity for the public and private sector 
to strengthen their all hazards disaster planning. CMS should work with 
ASPR, OASH, the CDC and state Medicaid programs to ensure a robust 
implementation including mock disaster exercises (table tops) in 
conjunction with local public health and/or regional HHS staff. 
Disaster plans should also require review to ensure adequate details 
such as representation in incident command meetings with emergency 
preparedness leads, logs tracking generator maintenance, generator fuel 
plans, and transportation contracts for evacuation.
    Congress should encourage the Administration to build a best 
practices tool kit for local regulation to support the development of 
state and local laws, ordinances, and policies that can provide 
additional protections for older Americans during disasters. These 
might include building permit expectations requiring elevators and 
emergency exit lighting be supported by generators.
Conclusion
    In closing, protecting those most vulnerable in our communities 
should continue to be our priority. Thanks to the combined efforts of 
the health care sector and first responders to apply solutions to 
lessons learned from previous challenges such as Hurricane Katrina, as 
a nation we are better prepared and more resilient to successfully 
address disaster response and preparedness for our seniors. We must 
ensure an ever more effective and rapid response to disasters that 
threaten older Americans. This applies not only to those older 
Americans living in institutions, but also to those in community based 
settings who can be more disenfranchised and at higher risk. What is 
also essential, is that we pay attention to their needs not only in 
disaster, but in their every day. Doing so is vital to ensuring that 
all communities across the Nation are prepared to respond to and 
recover from future public health disasters, fulfilling our collective 
promise to never again repeat the chaos, disorder, and despair that 
followed Hurricane Katrina.
    Thank you again for the opportunity to testify. I will be happy to 
work with you on any of these issues as you consider your opportunities 
to strengthen support for older Americans. I look forward to your 
questions.
                               __________
                        Questions for the Record
                        To Dr. Karen B. DeSalvo
                     From Senator Elizabeth Warren
    Climate change is the greatest disaster preparedness and response 
issue of our time. A 2016 publication by the Environmental Protection 
Agency noted that the consequences of climate changes are serious for 
us all, but particularly for older Americans. Additionally, the 
nation's population over age 65 is expected to nearly double by 2050, 
and approximately 1-in-5 older adults live in an area that was directly 
impacted by a hurricane or tropical storm within the last decade.\1\
---------------------------------------------------------------------------
    \1\ Environmental Protection Agency. ``Climate Change and the 
Health of Older Americans.'' (May 2016) (https://
19january2017snapshot.epa.gov/sites/production/files/2016-10/documents/
older-adults-health-climate-change-large-fonts_0.pdf)
---------------------------------------------------------------------------
    You have done considerable work looking at the social determinants 
of health--meaning all the social and economic factors that influence 
an individual's health.
Question:
    Is the environment a social determinant of health, and will the 
changing climate significantly impact the health outcomes of seniors?
Answer:
    Climate change has a significant impact on the social determinants 
of health. Its effect on clean air, safe drinking water, and access to 
food and shelter inarguably impacts the health of all Americans, 
including seniors. The World Health Organization has declared that 
climate change contributes to widening disparities in health equity and 
is responsible for 250,000 deaths worldwide each year.
    The American Public Health Association has compiled the ways in 
which climate change impacts the social determinants of health:

      Severe storms and floods can lead to water contamination, 
drowning, injury, mold, job insecurity, and vector-borne disease 
transmission.
      Extreme heat can cause dehydration, heat stroke, 
increased pollution and particulate matter, aggravated allergy and 
asthma symptoms, and worsened mental health, including dementia and 
schizophrenia.
      Drought-induced wildfires can harm lung and heart health 
as well as reduce access to healthy foods.

    Seniors experience unique vulnerabilities like low immunity, pre-
existing conditions, and limited mobility that put them at risk for 
these and other health threats associated with climate change such as 
heart disease, psychological stress, and falls.
Question:
    As the climate changes--as temperatures rise, air quality worsens, 
and flooding increases--what are the particular health risks posed to 
older Americans? What are the particular factors that increase the risk 
of climate change for older Americans?
Answer:
    Seniors live with a higher physiological risk for heat exhaustion 
and cold exposure due to a decreasing capacity to sense changes in body 
temperature. As a result, they are less able to adjust to changing 
temperatures around them. This is particularly challenging for seniors 
living on a fixed income who may not be able to afford adequate air 
conditioning or heating.
    Additionally, aging has other impacts such as loss of muscle 
strength, balance, and cognitive function that renders seniors less 
ambulatory. In the event of flooding, power outages, fire, or other 
disaster, they may find themselves unable to evacuate timely or at all. 
They are also less likely to be able to prepare for sheltering in place 
such as by stocking up on food and water since many no longer drive. 
Furthermore, hearing and sight loss may interfere with their ability to 
respond to disaster preparation or offers of help including 
recommendations to evacuate.
    Older Americans are also more likely to have multiple chronic 
health conditions, which require medications and medical devices for 
treatment and support. Power loss will interfere with cooling of 
medications such as insulin or prevent use of life-saving treatments 
such as use of electronically powered wheelchairs or oxygen equipment.
    Finally, because climate change can affect the quality of the air 
we breathe, seniors with respiratory conditions such as asthma or 
chronic obstructive pulmonary disorder will be at heightened risk for 
respiratory distress in events like wild fires that worsen air quality.
                               __________
                        From Senator Marco Rubio
Question:
    Are there new lessons that could be learned from Hurricanes Harvey, 
Irma, and now Maria?
    In particular, do you have any recommendations as to how we could 
better respond to the needs of dialysis patients--whether they receive 
care at an outpatient clinic or in their own home?
Answer:
    In order to respond to the needs of vulnerable populations during 
disaster, we need to know where they are so that first responders can 
prioritize their efforts to address these special needs first. When 
utilized, tools like emPOWER provide an unprecedented capacity to 
locate and respond to different patients with specific needs, like 
those undergoing dialysis. Currently emPOWER is limited in scope, only 
identifying individuals covered by Medicare. Expanding this program to 
a broader group of at risk individuals by using data from Medicaid and 
private payers would help first responders extend their impact in times 
of disaster. Of course, tools like emPOWER are only helpful if local 
officials are aware of the resource. Resources are needed to support 
training exercises by the Public Health Service Commission Corps to 
prepare members to use the tool in disaster response.
Question:
    What would you recommend to the families with loved ones in 
assisted living facilities or nursing homes about how to make sure a 
particular facility is able to respond to an emergency?
Answer:
    1. Families have an important role to play to see that their loved 
ones will be protected in times of disaster. There are a number of 
steps families can take to be better informed and to ensure that the 
institutions and their loves ones are prepared. They can begin by 
asking key questions of facilities. These should include questions 
about building readiness in disaster to support ``shelter in place'' 
and preparedness for evacuation.
    2. Families should ask about readiness to support sheltering in 
place, particularly regarding power backup system. It is not only 
important to ask whether the facility has a backup system, typically in 
the form of a generator, but also whether it has the capacity to power 
life sustaining parts of the facility such as the elevators and cooling 
and heating systems. They should inquire about whether the generator is 
raised above the flood plain, how frequently the generator's 
functionality is tested, how many days of fuel it can provide, and what 
the specific plans for fuel replacement entail. They should also 
inquire about staffing plans including access to higher level clinical 
care such as through an in-house nurse practitioner or telehealth 
opportunities.
    3. Communications systems are another important area to inquire 
about. They should understand when and how they will be contacted in 
the event of disaster. They should also understand whether the facility 
will have redundancy in systems supporting telecommunications and 
internet access.
    4. Families should also be clear about plans for evacuation in the 
event of emergency. They should be clear about whether and how their 
loved ones will be evacuated, including asking if the facility already 
has a transportation contract in place to support the evacuation. They 
should also understand any responsibilities the family may have, 
particularly if the family member resides in an assisted living 
facility. Additionally, families should inquire about plans for 
staffing during evacuation and whether there is a preexisting 
arrangement with a ``sister facility'' to serve as temporary shelter.
    5. Other actions a family can take include maintaining a list of 
doctors, medical problems, and medications. This can be on paper or 
electronic, but they should also see that they have access to their 
family member's electronic medical record of their primary care 
physician through their patient portal. For those family members with 
end of life wishes expressed in living wills, they should ensure that 
those documents and wishes are known to the facility, accessible 
electronically, and known to the family member's physician.
    6. Additionally, people should ensure that their family member or 
loved one is registered with the Medical Special Needs Registry with 
local health department. This is particularly important for seniors 
living in assisted living facilities or other community based settings. 
This will ensure that they are on a priority list for assistance 
before, during and after an event.
                               __________
  Prepared Statement of Kathryn Hyer, Ph.D., Professor and Director, 
   Florida Policy Exchange Center on Aging, School of Aging Studies, 
              University of South Florida, Tampa, Florida
                                  and
   David Dosa, M.D., MPH, Associate Professor of Medicine and Health 
 Services, Policy and Practice, Brown University, Associate Director, 
                               Center of 
 Innovation for Long Term Services and Supports, Providence VA Medical 
                                 Center
    On behalf of my colleague Dr. David Dosa who could not be here 
today, I would like to thank the Senators and the Senate Special 
Committee on Aging for providing the opportunity to testify here today 
on a topic that I have studied since 2004 when four hurricanes 
traversed Florida within 44 days. Since that time my colleagues and I 
have studied the effect of disasters on the frail older adults living 
in nursing homes and assisted livings and have worked to improve 
disaster preparedness, response, and recovery.
    I would like to focus my remarks on more than a decade's worth of 
research that has been carried out thanks to generous grants from the 
John A. Hartford Foundation, The Kaiser Family Foundation, The Borchard 
Foundation, and the National Institutes of Aging. My focus will be on 
the issue of evacuation of nursing homes; but for background, in 2004, 
Florida nursing homes only became part of local and state emergency 
management operations after repeated hurricanes crisscrossed the state 
and emergency management personnel finally recognized nursing homes 
needed help replenishing medical supplies, water, restoring power and 
getting fuel for generators to continue to operate.
    Following Hurricane Katrina, our research team interviewed nursing 
home administrators about their experiences during the storm. Across 
the board, these interviews revealed that administrators wrestled with 
the important decision of whether to evacuate their residents prior to 
the storm or ``shelter in place'' during a hurricane. Administrators 
noted to us that they were, ``damned if we do and damned if we don't'' 
in terms of the decision to evacuate. They cited pressure from 
emergency managers to leave their homes despite the difficulties of 
evacuating frail older adults on school buses to high school 
gymnasiums--often without adequate staffing and supplies. In general 
terms, many administrators noted that they saw patients decline, staff 
endure injuries moving residents, and believed more casualties occurred 
if they evacuated than if they remained in their own facility.
    This initial work became the impetus for a National Institutes of 
Health sponsored study that evaluated the effect of Hurricanes Katrina 
(2005), Rita (2005), Gustav (2008), and Ike (2008) on nursing home 
residents. This research eventually showed that among 36,389 NH 
residents exposed to the Gulf hurricanes, the 30 and 90 day mortality/
hospitalization rates increased considerably compared to non-hurricane 
control years regardless of whether they evacuated or sheltered in 
place. In total, there were 277 extra deaths and 872 extra 
hospitalizations within 30 days after exposure to anyone of the storms. 
While everyone suffers in disasters, our data indicate that exposure to 
natural disasters such as Hurricanes Harvey or Irma clearly results in 
excess death and hospitalizations among frail populations.
    Our research, however, does more than simply evaluate what 
hurricanes do to nursing home residents. We asked the simple question. 
Is it better to evacuate or shelter in place? Using the data from the 
four storms and some methodological techniques described more fully in 
our research, we concluded that the very act of evacuation prior to the 
storm increased the probability of death at 90 days by 2.7%-5.3% and 
increased the risk of hospitalization by 1.8%-8.3%, independent of all 
other factors. It should be noted that this data took into account the 
multiple deaths that occurred at St. Rita's and Lafon Nursing Homes 
during Hurricane Katrina. Despite these tragic deaths, evacuation 
proved to be cumulatively more dangerous then sheltering in place.
    Why it is potentially more dangerous to evacuate from a hurricane 
than to shelter in place? Definitive studies are not available but we 
offer several explanations:

    1. Hurricanes often deviate from their expected paths after the 
decision to evacuate must be made. In general, safe evacuations must 
occur at least 48-72 hours before landfall. Unfortunately, hurricanes 
make last minute turns and speed up or down. Hurricane Irma was 
expected to be a Category 4 making landfall near Miami. Many nursing 
homes evacuated west only to be evacuated a second time as Irma's path 
moved westward and threatened the very areas that residents had 
evacuated to.
    2. The evacuation of frail older adults is a logistics nightmare 
and requires exquisite planning prior to the event. Good materials 
exist to help with plans (http://www.ltcprepare.org/) but even under 
the best-developed emergency plans, evacuations create anxiety for both 
residents and staff that appear to have serious adverse outcomes.
    3. Older adults are susceptible to adverse outcomes whenever they 
transition from one environment to the next--even under optimal 
circumstances. Safe transitions require optimal communication among 
providers, keen knowledge of the patient, and access to medical 
records, correct medications, and appropriate supplies. In emergencies, 
transitions are seldom ideal and we have shown the consequence of such 
forced transitions in our hurricane research.
    4. Older adults with dementia represent a particular hardship for 
evacuating facilities. Without the cognitive ability to follow 
directions, or participate in their own self-care, residents with 
dementia suffer significantly during evacuations.
    5. Common comorbidities such as congestive heart failure, chronic 
obstructive pulmonary disease, and various cardiovascular diseases 
require clinician's knowledge of the resident, careful observation, 
adequate temperature control (e.g. air conditioning), and adherence to 
specific medication regimes, physical and occupational therapies, and 
specific dietary needs.
    6. Medical records and medications are often misplaced or poorly 
adhered to during disasters.
    7. Evacuations occur after the storm because nursing homes and 
assisted living may not be a priority for restoration of power. Florida 
had 40 nursing homes and 177 assisted living communities evacuate after 
the storm; the majority evacuated because their generators weren't 
operating correctly.

    Based on our research and experience, we have the following 
recommendations:

    1. Generators to support air conditioning and other medical needs 
must be required for both nursing homes and assisted livings. Ideally 
these generators need to be elevated to ensure continued operations 
during flooding. I am proud that last Saturday, Florida Governor Scott 
announced emergency rules requiring a generator and the appropriate 
amount of fuel to sustain operations and maintain temperatures at 80 
degrees or less for at least 96 hours following a power outage.

            http://www.flgov.com/wp-content/uploads/2017/09/AHCA916.pdf
            http://www.flgov.com/wp-content/uploads/2017/09/EN_DEA.pdf

    2. Emergency plans for nursing homes and assisted livings are not 
always available nor understood by residents or family members. 
Regulations must require that emergency plans for both nursing homes 
and assisted living be posted and available for inspection prior to 
admission. More work needs to be done to help people make choices based 
on posted disaster plans and to ensure the posted ``plan'' is actually 
a workable plan. Optimal preparedness means real drills and plans that 
are tested--even if only partially.
    3. Assisted living communities require more disaster preparedness 
oversight than they currently receive. We know older adults and 
disabled people want care in the community in less restrictive 
environments. Nevertheless, assisted living communities routinely 
accept patients that would only have received care in a nursing home a 
decade ago. Waiver payments for residents with Medicaid have also 
increased, thereby making the Federal Government an interested party in 
assisted living regulations. Currently, we don't even know whether a 
particular Medicare/Medicaid patient resides in an assisted living 
facility. This inadequacy in disaster response must be rectified.
    4. Evacuation must be nuanced and must take into account the size 
and severity of the storm, the ability of the facility to withstand 
wind and potentially storm surge, and the needs of the residents. 
Evacuation should not be ``all or nothing.'' There are times where 
certain medically complex patients (e.g., dialysis patients) might be 
more optimally treated with early evacuation while other more stable 
patients shelter in place. More research to identify the types of 
patients that benefit from evacuating or sheltering in place must be 
conducted.
    5. Nursing homes and larger assisted living communities must be 
built in places that minimize flooding risk and must be built to 
standards that allow administrators to shelter in place if at all 
possible.
    6. Every state and local emergency management organization in this 
country must identify and prioritize nursing homes and assisted living 
communities for restoration of services.
    7. Some degree of litigation protection must be considered for 
those facilities that abide by the regulations and provide care during 
disaster scenarios. Our research clearly shows that hurricanes affect 
all nursing home residents, regardless of whether they evacuate or 
shelter in place. Unfortunately, this did not prevent many 
administrators from being sued repeatedly for the heroic care that they 
provided following Hurricane Katrina.
    8. Finally, older adults matter. I am also the PI on a HRSA-funded 
Geriatric Workforce Enhancement Program grant. We believe that a 
continued commitment to geriatric education programs that help the 
nation's health workforce better serve the older and disabled 
population must be a priority. I can provide evidence today because the 
research and training developed after Hurricane Katrina has led to 
improved disaster response across the country. However, the funding 
rapidly dried up in the years that followed Katrina. Our country needs 
ongoing geriatrics training for population aging. We also need 
consistent research funding to evaluate the disaster needs of older 
adults and develop best practices. We know disasters will continue to 
occur and we must be prepared.

    Thank you for allowing this testimony.
                               __________
                        Questions for the Record
                          To Dr. Kathryn Hyer
                        From Senator Marco Rubio
    Dr. Hyer, in the recent tragedy at the nursing home in Hollywood, 
Florida, we have heard accounts that this nursing home had an emergency 
response plan in place and they simply were not following it.
Question:
    What are some of the ways we can create a backstop for instances 
like this, when emergency plans are not adequate or they are simply not 
followed?
Response:
    Background: According to the Centers for Medicare & Medicaid 
Services (CMS) interpretive guidance, the new Emergency Preparedness 
rule becomes effective November 15, 2017. Guidelines were issued in 
September 2016 and there were national training on the rule conducted 
in March 2017. CMS has good training materials for nursing homes on its 
Web site.
    Currently, in Florida, there is diffusion of responsibility between 
approval of nursing home emergency plans and the inspection of the plan 
in a specific nursing home by nursing home trained inspectors. The 
diffusion complicates coordination during disaster preparedness and 
during recovery as the Hollywood Hills nursing home exemplifies.
    The local county or city emergency operations center (EOC), 
generally a part of the Department of Health, reviews and approves the 
nursing home comprehensive emergency plan for that area. Then, the 
Agency for Health Care Administration (AHCA) inspects the nursing homes 
and verifies if the emergency preparedness plan is approved by the 
local EOC. During disasters and recovery there does not appear to be a 
standard protocol for AHCA participation at the local EOC. As Senator 
Collins says ``You shouldn't be exchanging business cards during a 
disaster.'' Yet, during Irma, many counties that did not have local 
AHCA staff present during the pre-emergency period nor during recovery. 
Many AHCA staff had no history of routinely working with the EOC during 
non-emergency events. Importantly, routine disaster preparedness drills 
and exercises at the local EOC level do not seem to routinely include 
local nursing homes, AHCA regional inspection staff in that area, or 
EOC personnel.
    At the state level, the Department of Health and the AHCA work 
together well, in my judgment. My experience is that during any 
emergency, the Emergency Support Function for Public Health (ESF-8), 
operated by the Department of Health, is staffed with high-ranking 
representatives from AHCA who inspect the nursing homes and assisted 
living facilities in Florida. I think the system at the state level is 
well coordinated and there seems to be excellent communication between 
and among the Department of Health, AHCA, and state associations for 
nursing homes and assisted living facilities. These new standards 
became effective during the 2004 storms and have been improving since 
then.
    At the county or city level, the EOC, the Department of Health and 
the local AHCA survey office do not communicate routinely and do not 
have a history of working together--that is the hallmark of the State's 
EOC.

Recommendations:

    1. Require the State of Florida's Field Operations for the Division 
of Health Quality Assurance within the AHCA to determine if the nursing 
home is compliant with the new emergency preparedness rules by using a 
survey protocol that has been developed with the EOC.
    2. Require generators and fuel for 96 hours. The rule hearings for 
both assisted living and nursing homes were held on November 3.
    3. Require that EOCs and nursing homes practice the emergency 
operations plans and that they report the practices. Require AHCA staff 
to be included in the simulations or table tops. To make this 
efficient, some coordination could occur using web-based reviews and 
participation. But, the plans must include both the Department of 
Health and the AHCA staff, as well as nursing home providers.

    a.  Any exercise should include an actual evaluation of the 
exercise using evaluation criteria that are available. (Did the home 
use an incident command system and actually use the written emergency 
plan when it was conducting its exercise? Did the nursing home submit a 
revised plan based on the exercise?)
    b.  Target and prioritize homes with more intensive emergency 
drills:

              Facilities that have lower quality ratings, such 
            as special focus facilities, or poor quality stars (one 
            star) might be required to participate in ``table top'' 
            exercises with others and the EOC.
              Facilities in flood evacuation Zone A might also 
            be required to conduct a partial emergency exercise where 
            they are required to evacuate one part of a home to 
            determine how viable the plan actually is and to test how 
            long it will take.

    4. Disaster plans should require a detailed staffing plan--how will 
nursing homes supplement staff to meet staffing requirements during 
disaster and during the recovery? Irma preparations began on Thursday, 
September 7, for most nursing homes in south Florida. Nursing home 
staff worked 12-hour shifts during preparation and then the recovery 
period began on Monday, September 11. While technically the staff may 
have had 12 hour rest periods, many must have been exhausted after 4-5 
days of working. Irma was an unprecedented storm because of its size 
but we must learn from it.

      Emergency plans should include staffing contingency 
plans, including who is responsible for high-level administrative 
staff, such as director of nursing and administrator during recovery if 
those staff leave.
      Penalties for not complying with the plan should be 
reviewed but clearly the agency already has the authority to close the 
facility and move residents to other facilities.

    5. New CMS guidelines require nursing homes to have power sources 
to keep ambient temperature between 71-81 degrees. However, rules don't 
specify how many rooms or areas must be covered. This should be 
specified in an emergency plan that includes details for sheltering in 
place. If the conditions are not met, the plan should provide how the 
nursing home would evacuate. Nursing homes must create plans to 
evacuate during recovery if they are not able to care for residents.
Question:
    Are there ways we could confirm emergency plans are being followed, 
apart from just relying on the word of the nursing home?
Response:
    Florida has good infrastructure for nursing home communication with 
EOCs. A review of adherence and enforcement is recommended.

FLHealthStat
    Florida leads the country because it has instituted a web-based 
tracking system--FLHealthStat--which is used by AHCA, the Florida 
Department of Health, and state and local emergency management offices 
to identify issues for all health care providers (hospitals, nursing 
homes, intensive care facilities, and assisted living communities). The 
FLHealthStat data base preserves information over disaster rather than 
the earlier tracking system which updated (overwrote) provider data 
until disaster ended.

      All nursing homes and assisted living communities must 
register in FLHealthStat.
      All nursing homes and assisted living communities are 
expected to update and report to AHCA in the FLHealthStat system 
before, during, and after the storm.
      During Preparation: AHCA and EOC use FLHealthStat to 
identify nursing homes and assisted living communities with unoccupied 
beds that should be able to accept new residents either from the 
community or from other providers.
      During Recovery: FLHealthStat includes measures of 
providers' status and critical needs, including power needs, resident 
needs, staffing needs, damage, and water outage.
      Re-entry Into Evacuated Home: Nursing homes that 
evacuated must obtain clearance from the EOC, fire marshal or AHCA, 
depending on if damage was sustained in the facility. If the disaster 
plan that was approved by the local EOC is deviated from at all, the 
facility must contact the local EOC to communicate the change in the 
plan and obtain approval.
      AHCA kept requesting associations to help providers to 
update information. AHCA is surveying providers to learn about 
opportunities for improvement in system.
      While FLHealthStat is an improvement over earlier 
systems, there were complaints the system was cumbersome.
      Potentially, sanctions or penalties for not reporting or 
updating the information might be appropriate, after a review of 
current rules and opportunities to improve the reporting system.
Senator Rubio
    Dr. Hyer, your testimony mentioned that nursing homes have not 
always been part of Florida's local and state emergency management 
operations, and they were ultimately included after Hurricane Katrina. 
In the days after Hurricane Irma, we heard reports about how a number 
of other facilities and providers were not designated as such by the 
state, local government, or electricity provider. This including 
nursing homes, assisted living facilities, retirement homes, oxygen 
providers and others.
Question:
    Do you know how often state and local governments update the lists 
of providers like these so they are able to quickly respond to their 
needs?
Response:
    I believe FLHealthStat includes licensed health care providers 
including nursing home, assisted living, hospices and home care. 
Retirement communities are not included. I do not know if medical 
equipment suppliers are included.
    Recommendation: Disaster plans, approved by the local EOC, should 
be publicly available for all health care providers.
Question:
    Are assisted living facilities and retirement homes fully 
incorporated in state and local government response plans--in Florida 
and elsewhere?
Response:
    Assisted living facilities are required to have disaster plans and 
to register with the Department of Health's web-based tracking system--
FLHealthStat--which is used by AHCA, the Florida Department of Health 
and local emergency management offices to identify nursing homes' 
status and critical needs.
    Recommendations for Assisted Living Communities: I think this is a 
new and important area for state and potentially federal oversight and 
coordination. Given the current use of assisted living communities for 
Medicaid waivers under long-term care supports and services, assisted 
living is an increasingly important part of community care. Many of the 
small assisted living communities provide care for low-cost and there 
are important implications for increased regulations on the viability. 
However, given that over 400 assisted living communities evacuated for 
Irma, their role in providing care for disabled and older adults is 
important.

    1. Opportunities for increased coordination between the Department 
of Health's EOC and AHCA is harder to achieve with assisted living. 
Florida licenses 3,003 assisted living communities with approximately 
94,000 beds. Because so many are small homes (under 16 beds), the 
ability to thoroughly review plans is more complicated.
    2. Assisted living communities are not licensed as health care 
providers. They are licensed under Chapter 429 and are considered 
``community dwellings''. Licensing requirements are different.
    3. Assisted living inspections also occur every 2 years unless 
there is a complaint. More frequent inspections, annually, is 
recommended. Disaster plans can then be reviewed annually and any 
drills can also be monitored.
    4. It has been reported that the utility companies did not have 
accurate data for some assisted living facilities because they did not 
register with the utility company as an assisted living facility. Some 
assisted living communities registered as a private home. It is not 
clear what the motivation is, but regulations should be reviewed to 
determine if assisted living communities must register with a utility 
as an assisted living community. It may be important to review the tax 
status on things like home-owners exemptions for small assisted living 
facilities as well.
    5. Assisted living requirements for disaster plans may need more 
thorough review by both the EOC and by AHCA inspectors.
    6. Assisted living communities disaster plans should be reviewed 
carefully by the EOC and made public on the AHCA Web site. New 
residents might be required to review and acknowledge they have seen 
and understood the disaster plan. Changes to the plan would have to be 
sent to all residents.
    7. Assisted living fines or sanctions for not complying with 
disaster plans need to be reviewed and perhaps changed based on 
experience with Irma.
                               __________
                        From Senator Bill Nelson
    Dr. Hyer, thank you for your research on disaster preparedness in 
nursing homes and long-term care facilities in Florida. I am still 
devastated about the 12 seniors who died after being trapped in a 
nursing home in high temperatures after Hurricane Irma knocked out the 
facility's power. The failure to transfer these seniors to a 
functioning hospital some fifty yards away is unacceptable.
    The Centers for Medicare and Medicaid Services (CMS) finalized a 
rule requiring facilities participating in Medicare and Medicaid, 
including nursing homes, to update their plans for disasters and 
coordinate with government agencies to ensure facilities are equipped 
to respond to an emergency. The regulation was finalized in September 
2016, and facilities are required to comply with this rule by November 
2017.
Question:
    Does the CMS emergency preparedness regulation address some of the 
problems that led to the deaths at the Hollywood nursing home? Does the 
emergency preparedness regulation go far enough?
Answer:
    The new CMS emergency preparedness regulations require nursing 
homes to have alternative sources of power and to have temperatures 
that do not exceed 81 degrees when power is lost. How well nursing 
homes will be able to comply with the regulations is an ongoing issue 
and enforcement is a powerful tool to be certain these rules are 
implemented. I believe the state inspectors have to receive additional 
training, especially the inspectors who generally do the fire and 
safety inspections. CMS guidance is also probably needed to teach 
inspectors how to review the plans and be able to determine if the 
proposed plan would actually provide the ambient temperatures required 
for the residents to be safe.
Question:
    How important is it for CMS and state governments to prioritize 
robust implementation of this rule and ensure facility compliance in 
states before another disaster hits?
Answer:
    It is critical for CMS to work with every state to make sure the 
state and local emergency management structures for health (ESF-8 
functions) include long-term care providers, specifically nursing 
homes. I do not believe that all states have nursing homes as part of 
the ESF-8 team at the state level. Florida only added nursing homes 
during the 2004 hurricane season.
    Most local EOCs do not have good representation of nursing homes 
within the local Emergency Operations Center. This is a critical 
breakdown in systems for two reasons.

    1. The new CMS rules require local EOCs to approve the disaster 
preparedness plans. If the EOC does not visit or recognize the needs of 
the nursing home, the plan can easily become a ``paper exercise'' not 
an actual plan that works.
    2. The EOC needs to include local nursing homes in the preparedness 
exercises. Robust preparedness requires EOCs to work with the nursing 
homes in a meaningful way that allows the EOC to protect nursing home 
residents and others in the community.
Senator Nelson
    As it is currently structured, Medicaid can respond to public 
health emergencies and natural disasters. As the needs go up, whether 
it's because more people become eligible because they've lost their 
jobs or homes, or their health needs grow, federal funding goes up 
automatically in response.
    The Graham-Cassidy amendment that was unveiled last week would cut 
$1 trillion dollars from Medicaid, according to the nonpartisan 
Congressional Budget Office. The bill would create a block grant, which 
provides a fixed amount of funding, and would cap the underlying 
Medicaid program.
    We've had three hurricanes in a matter of weeks, and the Medicaid 
program is especially important to hurricane recovery efforts. I am not 
only worried about my home State of Florida under this proposal, but 
also how Puerto Rico and the U.S. Virgin Islands will fare. As they 
struggle to recover from Hurricane Maria, their Medicaid programs are 
subject to a block grant that won't adjust for the greater demands as 
the islands recover.
Question:
    How would the Graham-Cassidy bill provide states with sufficient 
funding to respond to natural disaster like hurricanes? What happens 
when more people need health coverage or costs rise on a per-
beneficiary basis?
Answer:
    I do not have expertise in this area.
Senator Nelson
    I introduced the Protecting Seniors During Disasters Act with 
Senators Rubio, Casey and Collins. The bill would create a national 
advisory commission on seniors and disasters to provide expert advice 
to the U.S. Department of Health and Human Services on the unique needs 
of seniors.
Question:
    Given your experience, why do you think a national advisory 
commission on seniors and disasters is important? Do you believe a 
commission like this can strengthen disaster preparedness and response 
for older adults?
Answer:
    I think a national advisory commission on seniors and disasters is 
important and would identify ``best practices'' across the country that 
could be disseminated. It would make a difference because improved 
practices heighten the understanding that our nation needs to be 
prepared. Such a commission would reinforce the learning that has 
occurred since 2004 storms and Katrina.
                               __________
  Prepared Statement of Paul Timmons, President, Portlight Inclusive 
                       Disaster Strategies, Inc.
    Chairman Collins and Ranking Member Casey, thank you for the 
invitation to speak before the Committee on this important topic. My 
name is Paul Timmons, President of Portlight Inclusive Disaster 
Strategies. I have been working in the field of disaster preparation 
and response for people who are aging and those with disabilities for 
15 years and have led Portlight since 1997. In my time I will share 
with you some of my observations related to our most recent disasters 
and make a number of recommendations for improving disaster 
preparedness.
    As the news media began to cover the story of the horrific 
conditions at the Hollywood Hills Nursing Home in Hollywood, FL and the 
deaths of eight of their residents on September 13, Portlight 
Strategies had begun our 18th straight day of round the clock disaster 
response efforts to address the disproportionate impact of hurricanes 
Harvey and Irma on older adults and people with disabilities. Given 
that people with disabilities and older adults are two to four times 
more likely to die or be seriously injured in a disaster, the urgency 
of our work cannot be understated. The disproportionate rate of injury 
and death is due to poor planning, inadequate accessibility, and the 
widely shared but incorrect assumption that people with disabilities 
and older adults are ``vulnerable,'' ``special,'' or ``at-risk,'' 
simply because of their diagnoses or stigmatizing beliefs about 
disability and aging. In fact, older adults and people with 
disabilities are extremely valuable experts on emergency problem 
solving, with far more practice than younger people and people who 
don't navigate inaccessible environments and programs on a daily basis.
    Since August 26, our work at Portlight has been spent, around the 
clock, organizing lifesaving rescues with our partners, organizing 
delivery of food, water, generators, wheelchairs, medical equipment and 
supplies, sign language resources, addressing civil rights violations, 
answering non-stop calls to our hotline, and pointing people to 
lifesaving and life sustaining emergency resources to meet the critical 
needs of older adults and people with disabilities.
    We have organized daily national, state, and issue specific public-
private coordination calls between governments, the Red Cross, 
disability organizations, and stakeholders to optimize limited 
resources and minimize duplication of effort.
    For every heartwarming tale of heroism (and there are many), we are 
navigating the devastating stories from people who have not benefited 
from the considerable tax payer investments in local, state, and 
national emergency preparedness initiatives. Local resources, the most 
knowledgeable daily lifeline for people with disabilities and older 
adults, are rarely funded before, during, and after disasters, with 
federal funds and donations going to organizations without a local foot 
print or experience in meeting the daily needs of older adults and 
people with disabilities in the impacted areas.
    What has happened since the Post Katrina Emergency Management 
Reform Act was passed in 2007?
    Great progress was made for many years, primarily by heavily 
investing in whole community inclusive initiatives, with true 
partnerships between FEMA and disability and older adult led 
organizations.
    People with disabilities and those who are aging need to be at the 
table when planning for disasters. There is no more important time for 
the adage ``nothing about us, without us'' to be a reality. At the 
local, state, and federal levels, and in non-profit agencies dedicated 
to disaster preparation and response, those who are aging and disabled 
need to be both participants and leaders. Right now, most planning 
occurs ``FOR'' people with disabilities and older adults, not ``WITH'' 
us. Moving forward we need to ensure there is substantial leadership 
and participation during emergency planning.
    To truly include older Americans and Americans with disabilities in 
the planning process, the following issues need to be addressed in 
order to reduce injuries, avoid deaths, and ensure response is as 
effective as possible:

      Ensure communication about emergency services are 
broadcast and distributed in American Sign Language and clear, plain 
language in all cases when communication about a disaster is made to 
the general public;

      Ensure that all emergency response communications, 
including 911, 311, and 211 emergency and information lines are 
accessible;

      Ensure all building evacuation procedures include 
procedures for those who need mobility support, have sensory 
disabilities, intellectual disability, and anxiety and other mental 
health concerns, and that personnel are trained to implement those 
plans;

      Ensure that all transportation to evacuate older persons 
and those with disabilities are fully accessible, have personnel who 
know how to operate the vehicles and the accessibility features, and 
are available during the emergencies;

      Ensure access to food, water, medicine, and power;

      Ensure all information about what to do, where to go, and 
how to get help is available in accessible formats, including video 
with captioning, audio, and plain language formats;

      Ensure all shelters, including both general population 
shelters and ``special needs'' or ``special medical needs'' shelters, 
are ready to support older adults and those with disabilities and that 
personnel staffing those sites are trained to support people with 
disabilities and those who are aging;

      Ensure all shelters are accessible and have trained 
personal assistants, accessible showers and toilets, flexibility in 
meals to meet dietary restrictions and requirements, and equal access 
to communication;

      Ensure admissions to medical facilities and nursing homes 
are not substituted for meeting civil rights obligations to provide 
equal access to emergency services and programs in their community;

      Ensure that all tracking information systems are up-to-
date and personnel know how both to use the systems and maintain 
confidentiality;

      Ensure there is equal access to emergency registries 
operated by state, federal, and non-profit emergency programs;

      Ensure voluntary registries are not only used in 
preparation for a disaster but are actually used as part of the 
response;

      Significant delays (up to 30 days, if the caller could 
even complete their call) in receiving ``critical and immediate needs'' 
assistance from FEMA and Red Cross, despite announcements to apply;

      Ensure individuals who use service animals are admitted 
to shelters and are able to stay with their animals while in shelters; 
and

      Ensure individuals who use mobility devices, sign 
language interpreters, personal assistants, communication devices, and 
health maintenance items are not separated from those devices and 
services.

    Despite extensive planning, many of these items were not completed 
for the response to Harvey and Irma. We learned lessons from Katrina 
and Sandy but did not implement many of those lessons. Hopefully we 
will be able to implement more lessons from the most recent storms. The 
following are my priorities to improve responses to reduce injuries and 
save lives.

Recommendations
    1. Create an inclusive disaster relief fund for Independent Living 
Centers and other consumer controlled community disability and aging 
organizations to engage in emergency preparedness, response, recovery, 
and mitigation. Invest $1 billion over 5 years to serve the people of 
their community before, during and after disasters. Those who are aging 
and those with disabilities are the experts on housing, access to 
health maintenance services, accessible transportation, getting people 
back to work, and keeping people out of nursing homes. Currently, 
independent living centers and other consumer directed agencies receive 
no funding to do their emergency preparedness and disaster response, 
recovery and mitigation work. Funding for these efforts should not 
compete with first responders, public health, and state and local 
emergency managers. So it is essential to fund preparation and response 
work through separate sources.
    2. Establish a National Center for Excellence in inclusive 
Disability and Aging Emergency Management. The initial focus of the 
center should include community engagement, leadership, training and 
exercise development, evacuation, sheltering, housing, and universal 
accessibility. I suggest a budget of $1 billion over 5 years to stand 
up the center.
    3. Direct the U.S. Department of Justice, and provide the 
Department with resources, to monitor and enforce the use of all 
disaster funds to ensure compliance with the civil rights requirements 
of the Rehabilitation Act of 1973, as amended and the Americans with 
Disabilities Act of 1990, as amended.
    4. Provide Department of Homeland Security grant funds to 
specifically fund qualified and experienced Statewide Access and 
Functional Needs Coordinators for all states and territories. These 
coordinators would serve as statewide subject matter experts across 
preparedness, response, recovery and mitigation to engage and 
coordinate whole community collaboration among disability leaders, 
community organizations, first responders, emergency managers, public 
health and safety, private sector and other stakeholders.
    5. Conduct a study of the use of volunteers to determine efficacy 
in sheltering services to individuals with disabilities and older 
adults. Objectives of the study should include determining if the use 
of volunteers is adequate to comply with disability equal access and 
non-discrimination obligations.
    6. Refresh the Post Katrina Emergency Management Reform Act to 
better define State and Federal Government obligations to plan for, 
respond to, recover from, and mitigate all hazards in compliance with 
disability civil rights laws.
    7. Exempt the cost of disability related repairs and replacement 
from the FEMA Individuals and Households maximum grant ceiling 
(currently $33,300). Disability related repairs and replacement of 
durable medical equipment and other disability items includes replacing 
wheelchairs, customized vehicles, medical devices, entrance ramps, 
elevator installation to meet home elevation requirements, and other 
items that provide equal access for people with disabilities in 
recovering from a disaster.
    8. Establish an American Independence Corps, similar to FEMA Corps 
made up of at least 5,000 citizen members with and without disabilities 
to carry out planning and preparation activities in each state, DC and 
Territory year round.
    9. Direct FEMA and the Administration on Community Living to lead a 
coordinated effort across Federal Government agencies, the states, 
CBOs, foundations, and other sectors, with those who are aging and 
those with disabilities in leadership roles, aimed at achieving on-
going planning, preparation, and implementation of these 
recommendations.

    Implementing these recommendations will:

      Prevent, minimize, and rectify the institutionalization 
and/or loss of critical home and community based services for children, 
adults and older persons in the lead up to, during or following a 
disaster; and
      Increase the ready supply of accessible, adaptable, 
affordable, and disaster resistant permanent and temporary housing 
nationwide.
Conclusion
    Let me be very clear, most of the failures and shortfalls we 
address are a direct result of the failure to plan at the local and 
state level and the failure to place subject matter experts in 
leadership roles at every level coupled with failure to include people 
with disabilities and older adults as key stakeholders in planning 
efforts. This has been coupled with blatant disregard for the 
unwaiverable civil rights obligations associated with the expenditure 
of every federal dollar spent by government, grantees and contractors 
without any monitoring and enforcement by the Federal Government over 
its civil rights obligations. To further emphasize this point, there 
are no civil rights loopholes releasing anyone from their legal 
obligations in emergencies and disasters. Period.
    Despite years of planning, people with disabilities and older 
adults in Texas, Florida, and the U.S. Virgin Islands, and other 
hurricane impacted states have, once again, paid the price for our 
collective emergency planning shortfalls. Many thousands are still 
without the basic necessities to meet their independence, safety, and 
health maintenance needs. Most have been denied their basic right to 
equal access to federally funded emergency programs and services. We 
receive daily requests to assist people without food and water. Some of 
the people calling are in high rise buildings without power. Callers 
are unable to obtain prescription medications, return home from 
evacuation placement in nursing homes hundreds of miles away, having 
extreme difficulty in reaching FEMA and Red Cross to request assistance 
and being informed about wait times of up to 30 days for crisis and 
immediate assistance funds for food, water and medication.
    Effective practices for whole community inclusion must be led by 
experts in disability and aging inclusive emergency management. The 
people most knowledgeable about the needs in their own community are 
best suited to lead disaster response and recovery. We must find a way 
for these organizations to have adequate resources to do the complex 
and long-term work that is needed for people with disabilities and 
older adults to participate with government and the disaster business 
giants to get grants, donations, and tax payer dollars to optimize 
whole community inclusive disaster recovery.
    Portlight Strategies and our national Partnership for Inclusive 
Disaster Strategies stand ready to assist the American people to get 
this right.
    Thank you for allowing me this opportunity to share my experience 
and recommendations with the Committee and I stand ready to answer any 
questions you might have.

Portlight Inclusive Disaster Strategies, Inc. is a nonprofit, 
nonpartisan, disability inclusive disaster relief organization 
established in Charleston, SC, in 1997. Portlight Strategies does not 
receive federal funding.

Portlight Inclusive Disaster Strategies, Inc.
P.O. Box 14109
Charleston, SC 29422
(843) 817-0671
www.portlight.org
                               __________
                        Questions for the Record
                            To Paul Timmons
                     From Senator Elizabeth Warren
    Climate change is the greatest disaster preparedness and response 
issue of our time. A 2016 publication by the Environmental Protection 
Agency noted that the consequences of climate changes are serious for 
us all, but particularly for older Americans. Additionally, the 
nation's population over age 65 is expected to nearly double by 2050, 
and approximately 1-in-5 older adults live in an area that was directly 
impacted by a hurricane or tropical storm within the last decade.\1\
---------------------------------------------------------------------------
    \1\ Environmental Protection Agency. ``Climate Change and the 
Health of Older Americans.'' (May 2016) (https://
19january2017snapshot.epa.gov/sites/production/files/2016-10/documents/
older-adults-health-climate-change-large-fonts_0.pdf)
---------------------------------------------------------------------------
Question:
    As increased flooding, heatwaves, droughts, and other extreme 
weather events become more common, does America have the right 
preparedness plans in place, or do we need to be doing more to respond 
to the needs of seniors and those with disabilities?
Answer:
    Despite the huge investment in preparedness across the country 
through the development and implementation of the National Preparedness 
System, plans are only in place on paper in most communities. Where 
there is actual planning, it generally excludes older adults and people 
with disabilities, and where older adults and people with disabilities 
are included, the general perspective is that their needs are special 
and their contributions are not a key element of a whole community 
inclusive approach to universal accessibility and inclusion.
                               __________
                        From Senator Marco Rubio
    Your testimony emphasizes the importance of including older 
Americans when developing emergency response plans.
Question:
    In your experience, what are some common misunderstandings that you 
hear from state and local governments when it comes to meeting the 
needs of older Americans after a disaster?
Answer:
    Misunderstandings include:

      Accessibility is ``nice to have'' not required.
      Civil rights and equal access obligations associated with 
the use of federal funds can be waived in a disaster.
      Older adults and people with disabilities need to be 
``planned for'' rather than engaged as knowledgeable partners in whole 
community planning.
      Exercises can be effective without using real people with 
disabilities and older adults participating.
      It isn't necessary to fund accessibility experts and 
community organizations. Funding goes to generalists and practitioners 
without accessibility expertise, and this is adequate to meet 
obligations.
      Older adults and people with disabilities are 
``vulnerable'' and their needs are medical, rather than needing 
physical accessibility, effective communication accessibility and 
program accessibility to maintain health, safety and independence.
Question:
    Do the residents of nursing homes, assisted living facilities and 
others typically have the necessary level of information about how the 
facility plans to respond to an emergency?
Answer:
    Residents of nursing homes, assisted living and others rarely have 
access to actionable information to plan for, respond to and recover 
from emergencies and disasters. This is despite ongoing efforts to 
build and implement inclusive planning initiatives locally, statewide 
and nationally, and is an example of the deficiencies resulting from 
using generalists and medical approaches rather than accessibility and 
inclusion experts.
                               __________
                        From Senator Bill Nelson
    You emphasized the need for a commission or national infrastructure 
to connect and coordinate stakeholders involved in emergency 
preparedness. I introduced a bill with Senators Rubio, Casey, and 
Collins to create a national advisory commission to advise the 
Department of Health and Human Services on disaster preparedness for 
seniors. The commission would consist of Federal agency heads, local 
agency representatives, and non-Federal emergency healthcare 
professionals.
Question:
    Why are advisory commissions like the one described above 
important?
Answer:
    Disability leaders believe in the adage, ``nothing about us, 
without us''. We believe emergency preparedness must be inclusive, this 
means planning with us, rather than for us. Advisory boards are a tool 
for bringing subject matter experts with lived experience to the table. 
We would strongly encourage that the membership of the National 
Advisory Council include a majority of older adults and individuals 
with disabilities.
Senator Nelson
    You spoke at length about the need to promote inclusiveness in 
disaster preparedness and response plans for individuals with 
disabilities, and I fully agree. In your testimony, you stated that 
people with disabilities and older adults are two to four more times 
likely to die or be seriously injured in a disaster. In Florida, we are 
still in the process of recovering and rebuilding in the wake of 
Hurricane Irma. And Puerto Rico and the Virgin Islands are in the midst 
of a humanitarian crisis.
Question:
    What recommendations do you have for Congress, and State and local 
governments so that we improve disaster preparedness efforts to better 
account for older Americans and people with disabilities?
Answer:
    We strongly recommend monitoring and enforcement of the 
Rehabilitation Act requirements in all use of federal funds. Meeting 
the obligation to provide physical access, program access and effective 
communication access throughout all preparedness, response, recovery 
and mitigation activities actually offers a great opportunity to 
provide equal access and full inclusion through universal design. This 
is smart practice for optimizing limited resources and minimizing 
unnecessary use of medical and responder resources simply because of a 
lack of inclusive planning.
    It's time to directly fund local independent living centers and 
disability organizations. These are the experts on housing, health 
care, transportation and benefits navigation needs of older adults and 
people with disabilities. During and after disasters, they usually end 
up providing the services that the funded organizations are unfamiliar 
with. However, they are not funded and the impact on their resources 
limits services to both disaster survivors and individuals not impacted 
by the disaster.
    Finally, training and technical assistance in achieving and 
maintaining disability inclusive whole community readiness and 
resilience must be led by experts. Too many amateurs are using unproven 
practices, and failing to establish objectives or measure results. We 
strongly recommend the establishment of a National Center of Excellence 
in Whole Community Inclusive Emergency Management.
                               __________
Prepared Statement of Jay Delaney, Fire Chief and Emergency Management 
            Coordinator, City of Wilkes-Barre, Pennsylvania
    Chairman Collins, Ranking Member Casey, and members of the U.S. 
Senate Special Committee on Aging, thank you for inviting me here today 
to discuss how cities and towns across the country can help ensure the 
health, safety, and resilience of older Americans and individuals with 
disabilities during and after disasters.
    I am the Fire Chief for the city of Wilkes-Barre, Pennsylvania. I 
have been honored to serve the city in this role for over 12 years and 
a total of 36 years in Emergency Services. I am also the Emergency 
Management Coordinator for the city of Wilkes-Barre and a certified 
paramedic.
    Over 40,000 people reside in Wilkes-Barre, a city located in 
Luzerne County. Nearly 19 percent of the county's residents are over 
age 65, which is three percent higher than the average for the state. 
And, many of the older residents are concentrated within the city 
limits.
    Like any Fire Chief or Emergency Management Coordinator, I feel a 
great sense of responsibility for these older Pennsylvanians; many who 
live by themselves.
    My concern for their well-being is heightened whenever there is a 
threat of a severe storm or weather event.
    That is due to a 10,000 square mile watershed that drains into 
Wilkes-Barre from Susquehanna River, threatening to flood our streets 
and neighborhoods.
    In August 2011 the threat became very real as the east coast braced 
for Hurricane Irene and Lee to make landfall. What transpired over that 
next week explains why early weather tracking, data, surveillance and 
the flow of information across all levels of government is a priority 
and critical to the health and safety of residents.
    About seven days before the storms were scheduled to hit, we heard 
from the National Weather Service. They started to send us regular 
updates about the storm patterns and possible rainfall and potential 
crests for the Susquehanna River. The Pennsylvania Emergency Management 
Agency disseminated critical data to the County Emergency Management 
Officials and the emergency management coordinator for each 
municipality.
    Wilkes-Barre is protected by a U.S. Army Corp of Engineers levee to 
a river level of approximately 42 feet. The Susquehanna River crested 
on September 9, 2011 at a record and historic level of 42.66 feet.
    For years, the gauges that measured the water height of Susquehanna 
River in Wilkes-Barre were broken and were the responsibility of the 
U.S. Geological Survey. Senator Casey led the charge here in Washington 
to secure the resources to replace our broken gauges. It is because of 
Senator Casey that we can track--in real time--the possibility of a 
flood and critical river level data. This type of surveillance 
information provided the needed data to make risked based decisions for 
possible evacuation.
    Using maps of flooding that took place in 1972 after Hurricane 
Agnes, we created an evacuation zone. And, on September 9, 2011, we 
successfully evacuated 15,000 residents of Wilkes-Barre in about 10 
hours. This evacuation included Wilkes-Barre City Hall, Wilkes-Barre 
Police Headquarters and Wilkes-Barre Fire Headquarters as well as the 
entire downtown, King's College and Wilkes University.
    We alerted the local hospital and the two nursing homes in the 
evacuation zone. They executed their Emergency Preparedness Plans and 
safely evacuated over 250 seniors. And, if at any time, they thought 
that they were going to have trouble evacuating in the time required, 
they knew to request additional help from the Wilkes-Barre City 
Emergency Operation Center. We would send ambulances and personnel to 
help.
    But, it was the older Pennsylvanians, the seniors, and those with 
disabilities who still lived in their homes and in the community that I 
worried about most--the Mr. and Mrs. Smiths who have lived in their 
home for 50 years.
    In preparation for a possible evacuation, we had developed a grid 
designating areas of responsibility for Fire Department, the Police 
Department and members of the National Guard.
    We drove through South Wilkes-Barre and the downtown making 
announcements from our vehicles, knocking on doors, and posting 
evacuation orders. We knocked on every door. We left notes on doors of 
the homes where no one answered and made an additional check to ensure 
their evacuation. Most people heeded the request to evacuate on the 
first try, but if anyone resisted, they took their names and wrote down 
their addresses and we spent additional time working to get them out of 
their homes.
    We successfully executed our plan because of the seamless 
collaboration and communication among officials at the national, state, 
and local levels.
    But, even so, after every major event, we look back and discuss how 
we can improve. For example, should we ever need to evacuate again, we 
now have a contact in place with a local bus company that agreed to 
drive routes throughout the city to pick people up and take them to 
safety.
    Following Hurricanes Harvey and Irma, I hope that Congress will 
conduct its own after action review as it did after Hurricane Katrina 
in August 2005.
    While Presidential Directive 5 started the advancement of the 
National Incident Management System it was for the most part put into 
action after Hurricane Katrina and is a model for how all levels of 
government manage all types of emergencies and disasters. As part of 
that review, I hope that Congress will commit to continue to fully fund 
the National Weather Service and FEMA, and invest surveillance tools so 
that we have the most comprehensive information available before, 
during and after a disaster to guide our decision-making. Without early 
weather surveillance we have little time to plan and prepare for 
potential weather events.
    I am grateful to the Senate Special Committee on Aging for the 
opportunity to add my voice to this conversation.
    Thank you.

      
      
      
      
      
      
      
      
      
      
      
      
      
      
=======================================================================

                  Additional Statements for the Record

=======================================================================

                    Statement of Senator Marco Rubio
    I would like to thank our witnesses for their time and willingness 
to testify before the Senate Aging Committee, and I wanted thank Dr. 
Kathryn Hyer in particular for making the trip from my home State of 
Florida. The topic of disaster response for older Americans is 
especially important for states, like Florida, with a large senior 
population, and I thank you for your work.
    In the wake of a natural disaster, we can be painfully forced to 
grapple with our own shortcomings and failure to prepare for all 
scenarios. In the aftermath of Hurricane Irma, 11 senior citizens 
senselessly died in Hollywood, Florida. The victims in this particular 
case were later found to have body temperatures far above safe levels, 
some reaching nearly 110 degrees. According to the CDC, temperatures 
over 103 degrees puts people at risk of a heat stroke and that senior 
citizens are more vulnerable to high temperatures.
    My own mother is in an assisted living facility and I cannot 
imagine the pain that these victims' families must be dealing with.
    I am committed to working with my colleagues to fill the gaps in 
our current emergency response system, starting with legislation that 
Senator Bill Nelson and I introduced that would establish an Advisory 
Council on Seniors and Disaster. This legislation would require the 
heads of multiple federal agencies to assess the specific needs of 
seniors, our nation's current capacity to quickly meet those needs 
after a disaster, and work with state governments to ensure they have 
the necessary tools and capabilities to care for older Americans in the 
wake of a disaster.
    This advisory committee is only part of the solution, and I look 
forward to learning from our witnesses about other ways to fix this 
problem.
                               __________
     Statement of Katie Smith Sloan, President and CEO, LeadingAge
    LeadingAge appreciates this opportunity to comment on the need to 
improve planning, preparation and protection for vulnerable populations 
threatened by disasters such as the recent hurricanes in Texas and 
Florida. We commend the Committee's efforts to ensure the safety of 
America's older adults in emergency situations.
    The mission of LeadingAge is to be the trusted voice for aging. Our 
6,000+ members and partners include not-for-profit organizations 
representing the entire field of aging services, 38 state associations, 
hundreds of businesses, consumer groups, foundations and research 
centers. LeadingAge is also a part of the Global Ageing Network, whose 
membership spans 30 countries. LeadingAge is a tax-exempt charitable 
organization focused on education, advocacy and applied research.
    Vulnerable older adults must be protected in the event of disaster. 
This effort must involve collaboration between public and private 
agencies. Not only must older adults be kept safe during events like a 
severe storm or other natural disaster, but they often need assistance 
in the aftermath with services like food, fresh water, and electricity 
to power essential medical equipment.
    We support a three-pronged approach to emergency preparedness on 
behalf of older adults:

      A Federal regulation that will be effective November 15 
will require certain providers of health care and long-term services 
and supports to have plans for foreseeable natural and man-made 
disasters.
      Senators Bill Nelson, Marco Rubio, Bob Casey, and Susan 
Collins have introduced the Protecting Seniors During Disasters Act, 
which will establish a National Advisory Committee on preparing seniors 
for an emergency.
      Federal, state, tribal, regional and local emergency 
preparedness authorities must recognize the special needs of older 
adults and put this population and the organizations that serve them on 
priority lists for restoration of essential services.
Emergency Preparedness Final Rule
    On September 8, 2016 the Centers for Medicare and Medicaid Services 
(CMS) posted a final rule, Emergency Preparedness Requirements for 
Medicare and Medicaid Participating Providers and Suppliers. The rule 
becomes effective on November 15, 2017.
    The rule applies to all health care providers that participate in 
Medicare and Medicaid, including hospitals, nursing homes, hospice and 
home care agencies. Having an emergency preparedness plan in place will 
be a requirement or condition of participation in Medicare and Medicaid 
for all providers. The inspection or ``survey'' that nursing homes 
undergo annually will include a review of the nursing home's emergency 
preparedness plan.
    To implement the new requirement, providers are to take an ``all 
hazards'' approach, assessing the organization's vulnerability to 
natural and man-made disasters. The kinds of disasters for which 
providers must plan include emergencies related to patient care; loss 
of water or other utilities; loss of part of the facility, equipment 
failures, communication breakdowns, unavailability of food and 
medication shipments, and similar emergencies. Emergency preparedness 
plans must take into account the special needs of the populations the 
provider serves, such as limited mobility, dependence on medical 
equipment, etc.
    Providers must develop policies and procedures to protect residents 
and patients in the event of potential disasters, train their staff in 
these procedures, and regularly test the adequacy of the procedures. 
Staff training must include exercises conducted among senior staff in 
an organization and full-organization drills involving the entire 
staff. CMS guidance issued on the final rule includes consideration of 
evacuation plans and back-up evacuation plans in the event that the 
planned destination becomes inaccessible or is unable to accept more 
patients.
    The guidance notes that mobility can be an issue for many at-risk 
populations, including older adults and persons with disabilities. 
Emergency preparedness plans must ensure that transportation is 
available and that staff responsible for transporting older persons 
know the procedures to be followed. Alternative facilities that could 
be destinations for evacuated patients and residents will have to be 
identified, along with the financial resources that will be necessary 
to carry out the plan.
    Issues of potential leadership succession must be addressed in 
emergency plans, ensuring that personnel are available to fill critical 
decision-making roles. Plans also must include protection of vital 
records and health information technology.
    An important aspect of the emergency preparedness rule requires 
coordination and collaboration with public authorities in charge of 
emergency response. To comply with the new rule, providers will be 
required to document the ways in which they have collaborated with 
these public authorities in the development of their emergency 
preparedness plans.
    Since the final rule was issued last year, LeadingAge and its state 
partners have published and disseminated information for our member 
nursing homes, home care and hospice providers on developing and 
implementing the required emergency preparedness plans. We also have 
conducted numerous education sessions for our members, both in person 
and electronically. We will continue doing everything possible to 
ensure our members' successful compliance with the new requirement. And 
we urge the Special Committee to take the new rule into account in 
considering what action is needed to make sure that older adults are 
protected in the event of disasters.
Protecting Seniors During Disasters Act
    LeadingAge commends Senators Bill Nelson, Marco Rubio, Bob Casey, 
and Susan Collins for their introduction of this legislation, which 
will establish a National Advisory Committee on Seniors and Disasters. 
This kind of committee could encourage better coordination and 
collaboration among the various public and private entities responsible 
for proactive steps to ensure older adults' safety.
    We are pleased to see that a wide range of federal officials and 
agencies is to be represented on the Advisory Committee. We would 
recommend, in addition, that a representative from the Department of 
Housing and Urban Development (HUD) be added to the commission.
    Residents of public senior housing communities are especially 
vulnerable to damage to their homes and interruptions in their supply 
of food, water, and essential medications as a result of natural 
disasters. All too often following a disaster, we see that older adults 
with high needs living independently in their communities are not given 
priority by public authorities for emergency supplies of food, water 
and essential services.
    As an example of the kind of services needed by older adults living 
in the community, in mid-September LeadingAge and our member National 
Church Residences established the Hurricane Services for Seniors 
hotline. National Church Residences serves as a clearinghouse, matching 
needs for housing and services with older adults affected throughout 
Texas, Florida, and Puerto Rico. The hotline shares resources and 
connects callers with available housing. Service coordinators help 
guide the older adults through the steps of filing for federal and 
state assistance. The hotline is an example of a service that could be 
expanded through collaboration with the Administration on Community 
Living at HHS and HUD using a network of specially trained HUD-housing 
service coordinators.
    While their needs may be addressed to some extent by home health 
care agencies or other health care providers under the final rule 
discussed above, we are concerned that these older adults could fall 
through the cracks of public and private emergency preparedness plans. 
It is not just their medical and health care needs that must be 
addressed; restoring access to food and water is of critical 
importance. We therefore urge that an official responsible for senior 
housing programs within HUD be added to the advisory committee.
Older Adults Must Be Given Priority Status in Public Preparedness 
        Planning
    As discussed above, the final rule on emergency preparedness 
requires health care providers to document their efforts to work with 
public emergency and disaster preparedness authorities on plans to 
ensure older adults' safety.
    As our member organizations have worked on developing their plans, 
unfortunately they do not always have the cooperation of public 
authorities in their regions. In some areas, authorities apparently 
believe it is sufficient to give priority to the local hospital for 
restoring water and other utilities but not long-term care and senior 
housing.
    A broader view of priorities will be essential if the needs of 
older persons in emergencies are to be met. We urge the committee to 
use its influence with state and local authorities to make them aware 
of the importance of including all providers of services to older 
adults in their plans for responding to emergencies and disasters.
    LeadingAge commends the Committee for its attention to this 
critical issue and we look forward to working with you to ensure the 
safety of older persons during and after disaster strikes.
                               __________
        Statement of James R. Balda, President and CEO, Argentum
    On behalf of Argentum, which advocates for excellence in senior 
living, we thank you for holding a hearing on the important topic of 
the special needs of older Americans when it comes to disaster 
preparedness and response. This population is one of the nation's most 
valuable resources, but also one of the most vulnerable.
    Argentum is the leading national association exclusively dedicated 
to supporting companies operating professionally managed, resident-
centered senior living communities and the older adults and families 
they serve. Argentum member companies operate senior living communities 
offering assisted living, independent living, continuing care, and 
memory care services to older adults and their families. Since 1990, 
Argentum has advocated for choice, independence, dignity, and quality 
of life for all seniors.
    Argentum has worked with the senior living industry in all states 
to advance industry standards and regulations to ensure that all senior 
living communities continue to provide high quality care and quality of 
life as well as appropriate supports and services to the diverse array 
of residents served, including effectively preparing for the 
inevitability of natural disasters.
    Caring for a population that includes frail seniors in the face of 
a natural disaster offers many challenges, such as safe transportation; 
providing appropriate health services and nutrition; meeting the needs 
of people with special conditions such as dementia, limited ambulation, 
and vision or hearing impairments; ensuring there is access to medical 
records and life-saving medicines; emotional issues such as separation 
from loved ones and caregivers; vulnerabilities to those who prey on 
older adults through elder abuse; and other risks related to 
evacuation.
    As you know, the senior living industry is regulated in every state 
and must follow the relevant state laws, regulations, and codes to 
ensure the safety of community residents. States that are the most 
successful in integrating the needs of seniors in their emergency 
preparedness plans are those that offer clear, collaborative efforts 
between their emergency management and health agencies, and long-term 
care providers. Advanced planning, prevention, communication, and state 
and local partnerships are critical in helping to ensure the safety and 
well-being of older adults, especially those who are vulnerable in a 
disaster or emergency. Assisted living communities in each state are 
required to have an emergency management plan in place to rely on 
during a dynamic environment such as a natural disaster.
    We were heartened to hear that the nearly 190,000 residents and 
patients served in long-term care communities in Florida remained safe 
thanks to the smart planning of long-term care employees in preparing 
communities to cope with an emergency situation such as a natural 
disaster.
    For example, Legend Senior Living based in Wichita, Kansas, owns 
and operates eight Florida-based senior living and memory care 
communities, which house more than 640 residents and employ more than 
540 people across the state. A 24-hour command center was immediately 
organized at the home office in Wichita. Generators were tested and 
prepared for use. Nursing staff ensured that sufficient medication was 
in stock. Residence directors communicated with neighboring fire 
departments and hospitals to discuss possible emergency situations. The 
home office had calls with each community every four hours to ensure 
they were equipped and safe. When electricity went out, the phone 
system rolled to Wichita. The Florida communities worked hard to 
alleviate resident unease and were fortunate to have a chef who could 
continue to prepare meals and popcorn for residents to enjoy while 
watching football on television.
    Other providers that needed to evacuate residents sent them to 
sister communities nearby or in some cases companies rented out entire 
hotels to move in residents, staff, and their families. The widespread 
nature of these two disasters brought out the best in senior living 
providers. In Texas, memory care specialist Silverado took in 30 
patients from a hospital that needed to evacuate. Providers opened 
their doors to residents from nearby cities and towns who arrived wet 
and cold and were given warm clothes, food, and a place to stay.
    Every emergency situation is different. At some point, a decision 
must be made on whether to shelter in place or evacuate. It's not an 
exact science and as was demonstrated in Florida, hurricane paths can 
swiftly change. In Texas, the Dickinson-based community that received 
negative national attention was told to shelter in place by the city's 
mayor. At some point, that decision did need to be reversed when the 
rising waters filled the community. Thankfully, everyone was safely 
evacuated.
    Professionally managed senior living communities are structured to 
cope with the distinct needs that older adults pose in the face of 
natural disaster. Each stage of an emergency, whether sheltering in 
place or evacuation, must be treated differently when dealing with 
frailer adults than other populations. Community staff understand the 
custom care plans that an older adult may not be able to experience 
from a shelter or relief organization unfamiliar with a frail 
individual.
    Some valuable lessons were learned from Hurricane Katrina resulting 
in much better care in a natural disaster emergency. During the recent 
hurricanes in Florida and Texas, wrist bands with names and community 
were immediately placed on resident wrists along with medication 
identification. Families were notified where their loved ones would be 
taken in case of evacuation.
    We have all learned from past tragedies, and Argentum currently is 
in discussions with Florida and Texas officials about regulations that 
have proved effective. For example, Texas in 2011 passed a law 
prioritizing assisted living communities for restoration of electricity 
following an extended power outage. Assisted living is not on such a 
priority list in Florida. We must have thoughtful discussion about the 
role for generators, adequate fuel supply, and safety considerations 
such as significant fuel storage on the site of a caregiving community. 
Several of our member companies were unable to access fuel to power 
their community generators and buses post-Hurricane Irma and searched 
for gas as far away as Maryland and Tennessee.
    We also hope this situation spurs a discussion about a need to 
consider in the future possible alternative energy sources and 
technology uses that could help long-term care organizations navigate 
this issue successfully.
    Natural disasters are inevitable and can occur anywhere, at any 
time, in the United States. Argentum and its members have worked hard 
to elevate the importance of disaster preparedness. We take it very 
seriously. The lives of each and every resident is precious and let's 
not forget the caregivers who were the real heroes during these storms. 
They spent night after night in the senior living communities caring 
for residents and many were not able to be with their own families 
during this time. While the safety of the senior living residents took 
priority, many caregivers finally went home to realize they had lost 
everything. Many companies in Texas and Florida have been fundraising 
with company matching programs to help these employees get back on 
their feet. Argentum has pledged to match up to $50,000 in donations 
from the senior living industry to communities and employees negatively 
affected by Hurricane Harvey. Please see the Addendum that follows 
which highlights just a few of the many stories we received of 
compassionate care, heroism, and acts of kindness from residents, 
families members of residents, and staff members from communities 
across the states affected by the hurricanes.
    We look forward to continuing our dialog with you to ensure that 
all of our nation's seniors are housed safely at all times in a caring, 
nurturing environment. Argentum is available to further address any of 
these issues.
    We sincerely appreciate your consideration of these comments.
ADDENDUM

         Preparing and Caring in the Face of a Natural Disaster
         Senior Living Prioritizes Resident Safety and Comfort

Caring for Residents, Staff, and Community
    Below are a sampling of the many letters of appreciation and 
support that have poured in from family members following the recent 
hurricanes in Texas and Florida:

    Family Member of Belmont Village Resident (Texas): First I want to 
say I felt that you all handled the lock-down for the residents of 
Belmont Village Hunters Creek during Hurricane Harvey really well. I 
appreciate the e-mail updates and the 800 call-in number to stay up to 
date of daily on goings. I had complete peace of mind that my parents 
were well-cared for, busy, and kept in their normal routine during that 
stressful time. Also I don't think they had much understanding of what 
was going on outside the walls of the building, all over the city of 
Houston. So they were not frightened, for which I was very thankful. A 
heartfelt thank you goes out to you all.

    After Hurricane Harvey, Atria Senior Living held a Texas-Sized 
Feast at the Support Center--as did many of its communities across the 
country--to raise funds for Atria Cares and affected employees. So far, 
more than $200,000 has been raised.

    Family Member of Atria Evergreen Woods Residents (Florida): The 
most precious people in my life are those that raised me as a child. 
With many others in Florida and as Atria Evergreen Woods residents, 
they were confronted with the path of hurricane Irma in September 2017. 
While many citizens of Florida were struggling with the idea of 
evacuations, Atria had everything planned and under control. You moved 
your Atria residents to a location in Orlando. The fact that Atria had 
a preplan and a hurricane safe location ready was extremely re-assuring 
for me and my family. The larger success story comes with the level of 
service, support and care that the Atria employees gave to its 
residents in the Orlando location during and after the hurricane. My 
aunt and uncle raised me from very young and they mean everything to 
me. Living in New York, you can imagine how difficult it was for me to 
deal with the situation. The feedback I would like to give you, which I 
hope is cascaded to the service providers, is that they were given 
first class attention and service during this natural disaster.

    Medication Tech, Autumn Leaves of Estero (Florida): It was the most 
humbling experience I have ever had. This storm made me appreciate a 
lot of things and look at life differently. Autumn Leaves opened their 
doors to my family in order to keep them safe and us together. They 
opened their doors to help others affected by the pending storm. They 
kept all of us safe and free from harm. I would not change anything and 
would do it all over again to care for our residents and families!

    Retirement Management Center was able to give shelter to two senior 
brothers, who were neighbors from across the street.

    Retirement Center Management (Texas): On Sunday, August 27 around 
3 p.m., the community received a call from the nephew of Chris and 
Johnny, brothers who live across the street from a Retirement Center 
Management community. One is diabetic and the other is an amputee with 
a prosthetic leg. A person kayaking down the street was asked by the 
community staff to assist Chris across the street. The staff was 
concerned about him walking in the water since he had some open sores 
and is diabetic. The community nurses did an assessment when the 
brothers arrived at the building and were able to provide them shelter 
from the storm with a warm location, dry clothes, and food and water. 
The community served as an emergency storm shelter for more than 10 
people during the severe flooding.

    The Fountains at Boca Ciega Bay in St. Petersburg (Florida): 
Located right on the Bay, this community was ordered to evacuate two 
days before Irma hit. The task was nothing short of monumental, but 
every Watermark community has a custom, detailed Emergency Preparedness 
Plan and the Fountains at Boca Ciega Bay followed each step for a 
successful evacuation and return. Details range from ``unplug computers 
and appliances'' to ``arrange for pharmacy and follow all medical 
charts'' and ``coordinate buses with chair lifts and bathrooms'' plus 
everything in between. Residents of our independent neighborhood 
evacuated to the Mission Inn, a resort hotel an hour or two from the 
community. Temporary housing in a big ballroom provided a safe 
experience and the hotel staff worked tirelessly alongside our 
associates to ensure a positive experience. Residents played games and 
cards thanks to quick thinking community life associates who grabbed 
them all on the way out. Exercise programs, club meetings and classes 
were held with enthusiasm to keep the days fun and to offer residents a 
routine as close to our typical lifestyle as possible. One resident 
brought her harmonica and entertained folks during and after the storm, 
with sing-a-longs of everyone's favorites.

    Resident at Five Star Senior Living, Horizon: The staff was 
absolutely wonderful during this hurricane. Many stayed here to assist 
and the attitude was one of what can we do to help--friendly, smiling, 
eager to please--which combined with older people already upset and 
sometimes confused, was a real positive attribute in these 
circumstances. The nurse remained on duty the entire time checking in 
on every resident who might have needed her aid. Our Director was here 
full time during the hurricane, as were several of the sales staff and 
servers.

    Resident at Brookdale First Colony (Texas): During the weeks and 
days that Harvey waged his ``war'' on our State, I was moved by the 
care and love which emanated from Brookdale First Colony staff who 
remained with us during the deluge. They calmed our nerves, welcomed 
our displaced relatives with open arms and were deeply concerned for 
all. They say heroes are made in times of war. These associates were 
our heroes and deserve Medals of Honor.
Uniting and Rebuilding
    Many senior living companies quickly rallied resources to ensure 
staff and communities negatively affected by these natural disasters 
were taken care of. Here is a sampling of their efforts:

    Watercrest Senior Living Group of Vero Beach, Florida is 
spearheading a $100,000 fundraising initiative coined `Watercrest 
CARES' in support of Samaritan's Purse for Hurricane Harvey disaster 
relief. Samaritan's Purse is a Christian organization led by Franklin 
Graham, son of Billy Graham, serving victims of disaster worldwide. 
Watercrest principals, Marc Vorkapich, CEO and Joan Williams, CFO, 
launched the `Watercrest CARES' fundraising campaign with a starting 
donation of $10,000, encouraging others to contribute to the campaign's 
relief efforts.

    Sunrise Senior Living community The Fairfax held a ``fill the 
truck'' fundraiser on September 21 to benefit those affected by Harvey 
and Irma. The Army Retirement Foundation-Potomac, a 501c3 charitable 
organization that founded The Fairfax Military Retirement Community 
near Fort Belvoir, VA, is also managed by Sunrise Senior Living. Co-
hosted along with TAD Relocation (TAD relocation assists in planning 
and downsizing of residents moving into The Fairfax and other senior 
living communities), a Fill a Truck event was held today to collect 
items by those affected by Hurricane Harvey. They filled the entire 
truck (a 26 foot moving truck!) with donations of clothing, bedding, 
hygiene and personal care products, children's toys, furniture, food, 
kitchen items, and pet items.

    Legend Senior Living based in Wichita, Kansas, with communities in 
Florida, set up a $20,000 fund for associates impacted by the storm, 
and other Legend associates gave another $5,000 to it. It is helping 
associates who have flooded homes, cars, and the many who lost power 
who had to re-stock the refrigerator. The company housed all our 
associates 24-7 who worked during the hurricane's passing as well as 
their families. They said they felt safer in the Legend building than 
at home.

    Belmont Village financial contributions to the company's relief 
fund, BVCares, now total $106,000 including the company match, creating 
a source of critical support funds to help Belmont's staff recover from 
damage to home and property.

    Atria Senior Living raised over $200,000 for their Atria Cares, an 
employee-funded nonprofit organization that provides emergency 
financial assistance to Atria staff in need.
Best Practices and Lessons Learned
    The senior living industry has applied its knowledge gained over 
the decades of caring for older adults, including best practices 
gleaned from coping with natural disasters. Here are some of the 
highlights from lessons learned that made senior living able to 
successfully navigate many of the challenges presented by hurricanes 
Harvey and Irma.

    1. The decision of whether to evacuate or shelter in place is a 
complicated process that requires a complete and thorough assessment of 
the situation. Both options have advantages and challenges. But 
assisted living providers are prepared for both through the development 
of emergency disaster management plans. State rules require that 
communities have food, water, and other necessary supplies for 
emergency situations that require sheltering in place. Plans also need 
to specify procedures for evacuations.

    2. In addition to well thought out emergency plans, regularly 
scheduled drills involving team members and residents is critical to 
the successful implementation of the plans.

    3. States that are the most successful in integrating the needs of 
seniors in their emergency preparedness plans are those that offer 
clear, collaborative efforts between their emergency management and 
health agencies, and long-term care providers.

    4. Advance planning, prevention, communication, and state and local 
partnerships are critical in helping to ensure the safety and well-
being of older adults, especially those who are vulnerable in a 
disaster or emergency.

    5. Companies with a headquarters outside of the affected zone can 
take on many of the administrative and coordination responsibilities to 
free up staff to care for residents. For example, Legend Senior Living 
based in Wichita, Kansas, owns and operates eight Florida-based senior 
living and memory care communities, which house more than 640 residents 
and employ more than 540 people across the state. A 24-hour command 
center was immediately organized at the home office in Wichita. The 
home office had calls with each community every 4 hours to ensure they 
were equipped and safe. When electricity went out, the phone system 
rolled to Wichita.

    6. Other providers that needed to evacuate residents sent them to 
sister communities nearby or in some cases companies rented out entire 
hotels to move in residents, staff, and their families

    7. Providers opened their doors to residents from nearby cities and 
towns who arrived wet and cold and were given warm clothes, food, and a 
place to stay. In Texas, memory care specialist Silverado took in 30 
patients from a hospital that needed to evacuate. In at least one 
example, the assisted living community took in elderly living alone in 
their own homes who did not have the supplies necessary to survive the 
hurricane.

    8. Many lessons were learned from Katrina. For example, during the 
recent hurricanes in Florida and Texas, wrist bands with names and 
community were immediately placed on resident wrists along with 
medication identification. Families were notified where their loved 
ones would be taken in case of evacuation.

    9. Autumn Leaves offered real-time updates on Web sites during each 
of the recent hurricanes for friends and family to get up to the minute 
information on their affected communities.

      http://autumnleaves.com/hurricane-harvey-update/ (Harvey)
      http://autumnleaves.com/hurricane-irma-update/ (Irma)

    10. Argentum is establishing an Emergency Preparedness Standards 
Board to develop assessment tools, sample plans and training to senior 
living providers in the emergency preparedness efforts.
                               __________
Statement of Teresa Osborne, Pennsylvania Secretary of Aging, and Rick 
       Flinn, Director, Pennsylvania Emergency Management Agency
    Chairman Collins, Ranking Member Casey, and Members of the 
Committee, thank you for holding a hearing to examine disaster 
preparedness and response for older Americans.
    September is National Preparedness Month and this year's theme is, 
``Disasters Don't Plan Ahead. You Can.'' Recognizing that we are in the 
immediate aftermath of Hurricane Harvey and Hurricane Irma, disasters 
like these serve as a reminder that each of us must be prepared for 
emergencies that can easily affect us where we live, work, or visit.
    Being prepared for the next potential emergency is a top priority 
for the Wolf Administration. As such, the Pennsylvania Emergency 
Management Agency (PEMA) and the Department of Aging have been engaged 
in conversations about emergency preparedness and Pennsylvania's older 
population. A recent survey conducted by PEMA revealed that only 26% of 
Pennsylvanians age 65 and older have a plan in place for when disaster 
strikes. This sobering statistic tells us that we all have friends, 
family, neighbors, and consumers who have no plan for how to act when a 
disaster is imminent, don't know how to respond after one has struck, 
and may not know how to communicate if they need assistance.
    Older Pennsylvanians have some of the same needs as the general 
population during a human-made or natural disaster. However, for older 
adults and persons with disabilities, they may also have a wider 
variety of functional limitations and some additional challenges to 
consider, including medical equipment, accessibility and transportation 
issues, and access to prescription medications. Approximately half of 
those over age 65 have two or more chronic health problems, such as 
heart disease, diabetes, and Alzheimer's disease. These conditions 
increase a person's vulnerability during periods of time without food, 
water, shelter, and adequate rest. According to the 2010 U.S. Census, 
of the older adults who were living outside nursing homes or hospitals, 
nearly one third (11.3 million) lived alone. This reality makes the 
creation and maintenance of a support network particularly important.
    Because emergencies and disasters strike quickly, you might be 
forced to evacuate your neighborhood or be prepared to be confined to 
your home. While first responders and relief workers will quickly be on 
the scene, they may not be able to reach everyone immediately, meaning 
that help may arrive in hours or even days depending on the extent of 
damage. What would you do if your basic services: water, gas, 
electricity, or communications, were cutoff? Even if you have physical 
limitations, you can still learn how to protect yourself and cope with 
disaster by planning in advance and by working with those in your 
support network: your family, neighbors, friends, and caregivers, as 
well as your local responders as a team.
    During September, the month dedicated to emergency preparedness, we 
are encouraging all older Pennsylvanians and their families to be 
informed, prepared, involved and ready. We are sharing three easy steps 
that they can take:

    1.  Visit www.ready.PA.gov to take the ``Ready PA Preparedness 
Pledge''
    2.  Download the ``Get Ready Now'' pocket guide, a 3-step guide on 
emergency preparedness for older adults. To access the guide, go to 
www.aging.pa.gov, hover your mouse over the ``Publications & Reports'' 
dropdown, then click on ``Emergency Preparedness'' (Direct link: 
www.aging.pa.gov/publications/documents/Seniors.pdf)
    3.  Call your local Area Agency on Aging (AAA), which is poised to 
participate on every level of emergency preparedness planning, and meet 
the needs of the communities they serve in times of crisis. Find your 
local AAA at www.aging.pa.gov/AAA

    We are sharing these steps with the Committee to the extent that 
they can be used as a model for other States, in taking extra 
precaution in preparing for a disaster. Pennsylvania will continue to 
be a leader in the area of preparedness and response, and we look 
forward to working with the Committee to ensure older adults across the 
Commonwealth and country are prepared for the possibility of a 
disaster.
```