Disaster Preparedness: Limitations in Federal Evacuation Assistance for Health Facilities Should be Addressed
Published: 2006-07-20T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Hurricane Katrina demonstrated difficulties involved in evacuating communities and raised questions about how hospitals and nursing homes plan for evacuations and how the federal government assists. Due to broad-based congressional interest, GAO assessed the evacuation of hospital patients and nursing home residents. Under the Comptroller General's authority to conduct evaluations on his own initiative, GAO examined (1) the challenges hospital and nursing home administrators faced, (2) the extent to which limitations exist in the design of the National Disaster Medical System (NDMS) to assist with patient evacuations, and (3) the federal requirements for hospital and nursing home disaster and evacuation planning. GAO reviewed documents and interviewed federal officials, and interviewed hospital and nursing home administrators and state and local officials in areas affected by Hurricane Katrina in Mississippi and Hurricane Charley in Florida.
section_title: What GAO Found
paragraphs: Hospital and nursing home administrators faced several challenges related to evacuations during recent hurricanes, including deciding whether to evacuate or stay in their facilities and "shelter in place", obtaining transportation necessary for evacuations, and maintaining communication outside of their facilities. Administrators took steps to ensure that their facilities had needed resources--including staff, supplies, food, water, and power--to provide care during the hurricane and maintain self-sufficiency immediately after. However, when evacuations were needed, facility administrators said that they had problems with transportation, such as securing the vehicles needed to evacuate patients. Although facility administrators had contracts with transportation companies, competition for the same pool of vehicles created supply shortages when multiple facilities in a community had to be evacuated. In addition, communication was impaired by hurricane damage. For example, a nursing home in Florida was unable to communicate with local emergency managers. NDMS is a partnership of four federal agencies, and has two limitations in its design that constrain its assistance to state and local governments with patient evacuation. The NDMS partners are the Department of Defense, the Department of Health and Human Services (HHS), the Department of Homeland Security (DHS), and the Department of Veterans Affairs; DHS is the lead agency. The first limitation is that NDMS evacuation efforts begin at a mobilization center, such as an airport, and do not include short-distance transportation assets, such as ambulances or helicopters, to move patients out of health care facilities to mobilization centers. The second limitation is that NDMS supports the evacuation of patients needing hospital care; the program was not designed nor is it currently configured to move people who do not require hospitalization, such as nursing home residents. Although NDMS moved nursing home residents due to Hurricane Katrina who were brought to mobilization centers, NDMS officials had to make special arrangements for people in need of nursing home care because NDMS lacked preexisting agreements with nursing homes. Neither of these limitations is addressed in other documents GAO reviewed, including DHS's National Response Plan (NRP). At the federal level, HHS's Centers for Medicare & Medicaid Services (CMS) has requirements related to hospital and nursing home evacuation planning as a condition of participation in the Medicare and Medicaid programs. CMS requires that hospitals maintain the overall hospital environment to assure patient safety, including developing plans that consider the transfer of patients to other health care settings. For nursing homes, CMS requires that plans meet all potential emergencies and disasters; however, requirements do not specifically mention the transfer of residents. In addition to assessing compliance with CMS requirements, the Joint Commission on Accreditation of Healthcare Organizations, the American Osteopathic Association, and states can also have additional emergency management requirements.

section_title: Letter
paragraphs: On August 29, 2005, Hurricane Katrina struck near the Louisiana- Mississippi border and became one of the worst natural disasters in U.S.  history. Hurricane Katrina affected a large geographic area and  necessitated the evacuation of parts of the area. Among those needing to  be evacuated were people in health care facilities such as hospitals and  nursing homes. During disasters such as Hurricane Katrina, administrators  of hospitals or nursing homes must make decisions about the best way to  care for their patients or residents under such circumstances, including  whether to evacuate if the facility becomes unable to support adequate  care, treatment, or other services. Moreover, if administrators decide to  evacuate, hospital patients or nursing home residents may need special  equipment or have other complicating factors which inhibit their  movement, thereby increasing the risk to their safety during the  evacuation process. Due to Hurricane Katrina, efforts were made to  evacuate hospital patients and nursing home residents. In the storm’s  aftermath, congressional reports raised questions about how health care  facility administrators plan for hurricanes, how they implement their  plans, and how the federal government assists health care facilities and  state and local governments with facility evacuations.
Federal, state, and local governments, as well as individual health care  facilities, have plans for how they will respond to emergencies such as  hurricanes. At the federal level, the National Response Plan (NRP)  provides a framework for how the federal government is to assist states  and localities in managing domestic incidents, including both incidents of  national significance and those of lesser severity. A program identified in  the NRP, the National Disaster Medical System (NDMS), can assist state  and local governments with evacuations of patients who need hospital  care. NDMS is a partnership of four federal agencies, and the Department  of Homeland Security (DHS) is the lead agency. At the state and local  levels, governments often have comprehensive emergency management  plans that mirror the NRP. At the individual facility level, hospitals and  nursing homes that participate in the Medicare and Medicaid programs  must comply with requirements established by the Department of Health  and Human Services’ (HHS) Centers for Medicare & Medicaid Services  (CMS). Compliance with these requirements is assessed by accrediting  organizations such as the Joint Commission on Accreditation of  Healthcare Organizations (JCAHO) and the American Osteopathic  Association (AOA), and state agencies.
Due to broad-based congressional interest, we assessed the evacuation of  hospital patients and nursing home residents due to hurricanes. We  performed this work under the Comptroller General’s authority to conduct  evaluations on his own initiative. In February 2006, we reported on  preliminary observations from our work, and in May 2006, we testified on  our preliminary observations before the Senate Special Committee on  Aging. To complete our assessment, we examined (1) the challenges  hospital and nursing home administrators faced related to recent  hurricanes, (2) the extent to which limitations exist in the design of NDMS  or other federal programs to assist state and local governments with  patient evacuations, and (3) the federal requirements for hospital and  nursing home disaster and evacuation planning.
For our first objective related to the challenges hospital and nursing home  administrators faced related to recent hurricanes, we reviewed  documents, including emergency management plans from state and local  governments and hospitals and nursing homes in Florida and Mississippi.  We interviewed officials in Mississippi who experienced Hurricane  Katrina, including officials from five hospitals, three nursing homes and  assisted living facilities, state officials, and local emergency management  officials in two counties. We also interviewed officials in Florida in areas  that experienced hurricanes in 2004, particularly those affected by  Hurricane Charley, which was the strongest hurricane to hit the United  States since Andrew hit southern Florida in 1992. In Florida, we spoke  with officials from three hospitals and three nursing homes, state officials,  and local emergency management officials in two counties. We also  interviewed officials from national hospital and nursing home  associations, Florida hospital and nursing home associations, and a  Mississippi nursing home association. For our second objective  concerning the extent to which limitations exist in the ability of NDMS or  other federal programs to assist state and local governments with patient  evacuations, we reviewed federal documents such as the NRP, including  the September 2005 draft Catastrophic Incident Supplement to the NRP.  We also interviewed officials from the Department of Defense (DOD),  HHS, DHS, the Department of Transportation (DOT), and the Department  of Veterans Affairs (VA), including officials who are responsible for NDMS,  asking about moving patients out of facilities and out of the affected areas.  For our third objective on federal requirements for hospital and nursing  home disaster and evacuation planning, we reviewed CMS documents  describing hospital and nursing home emergency planning requirements  that specifically relate to evacuations. We also interviewed officials from  CMS, JCAHO, and AOA concerning these requirements, as well as officials  from national hospital and nursing home associations, Florida hospital and  nursing home associations, and a Mississippi nursing home association. In  addition, we interviewed officials and obtained documents from the  Florida Agency for Healthcare Administration and Mississippi Department  of Health concerning state hospital and nursing home requirements for  evacuation. For additional information on our scope and methodology, see  appendix I. Our work was performed from October 2005 through July 2006  in accordance with generally accepted government auditing standards.
subsections: section_title: Background
paragraphs: At the federal level, the NRP provides a framework for how the federal  government is to assist states and localities in managing emergencies and  major disasters. NDMS is one of the programs identified in the NRP that  can supplement state and local medical resources during emergencies,  including providing resources to assist with evacuation. At the individual  facility level, hospitals and nursing homes must comply with CMS  requirements to participate in the Medicare and Medicaid programs.  Several recently issued federal reports have looked at the adequacy of  health care facility disaster planning, as prompted by Hurricane Katrina.
subsections: section_title: The National Response Plan
paragraphs: In December 2004, DHS issued the NRP to consolidate existing federal  government emergency response plans into a single coordinated plan, as  mandated by the Homeland Security Act of 2002. The NRP provides a  framework for how the federal government is to assist states and localities  in managing domestic incidents, including an “emergency” or a “major  disaster” declared by the President under the Robert T. Stafford Disaster  Relief and Emergency Assistance Act (Stafford Act). On May 25, 2006,  DHS revised the NRP to address certain weaknesses or ambiguities  identified following Hurricane Katrina.
The NRP includes a Catastrophic Incident Annex, which provides for an  accelerated, proactive national response to catastrophic incidents— defined as any natural or manmade incident, including terrorism, resulting  in extraordinary levels of mass casualties, damage, or disruption severely  affecting the population, infrastructure, environment, economy, national  morale, and/or government functions. By definition, a catastrophic  incident almost immediately exceeds resources normally available to  state, local, tribal, and private-sector authorities in the impacted area. A  separate Catastrophic Incident Supplement, which was drafted but had  not been approved at the time of Hurricane Katrina, provides additional  detail on the roles and responsibilities of federal, state, and local  responders during catastrophic incidents. However, as of June 2006, the  supplement had not been finalized.
Among its many components, the NRP establishes 15 emergency support  functions (ESF), which identify resources and define the missions and  responsibilities of various federal agencies in helping coordinate support  during incidents of national significance. For each of the NRP’s 15 ESFs,  which include Transportation, Communications, Firefighting, and Public  Health and Medical Services, the NRP designates a federal agency as the  ESF coordinator responsible for pre-incident planning and coordination. It  also designates one or more primary agencies to be responsible for  operational priorities and activities, coordinating with other agencies and  state partners, and planning for incident management. HHS, for example,  is designated as the ESF coordinator and the primary agency for ESF #8— Public Health and Medical Services.
section_title: The National Disaster Medical System
paragraphs: NDMS, one of the programs included in ESF #8—Public Health and  Medical Services—of the NRP, was formed in 1984 to care for massive  numbers of casualties generated in a domestic disaster or an overseas  conventional war. It is a nationwide medical response system to  supplement state and local medical resources during disasters and  emergencies and to provide back-up medical support to the military and  VA health care systems during an overseas conventional conflict. DOD,  HHS, DHS, and VA are federal partners in NDMS. These partners most  recently signed a memorandum of agreement in October 2005 that  describes the roles and responsibilities of each partner. DHS has the  authority to activate NDMS in response to public health emergencies,  which include, but are not limited to, presidentially declared emergencies  or major disasters under the Stafford Act.
NDMS consists of three key functions:    medical response, which includes medical equipment and supplies, patient  triage, and other emergency health care services provided to disaster  victims at a disaster site through NDMS medical response teams such as  Disaster Medical Assistance Teams (DMAT);    patient evacuation, which includes communication and transportation to  evacuate patients from a mobilization center near the disaster site, such as  an airport, to reception facilities in other locations; and  “definitive care,” which is additional medical care—beyond emergency  care—that begins once disaster victims are placed into an NDMS inpatient  treatment facility (typically a nonfederal hospital that has signed an  agreement with NDMS).
DHS has lead responsibility for the medical response function of NDMS.  DOD takes the lead in coordinating patient evacuation for NDMS, in  collaboration with DOT, the other NDMS federal partners, and commercial  transportation companies. VA and DOD share lead responsibility for  arranging definitive care, including tracking the availability of beds in  hospitals that participate in NDMS.
NDMS was used to supplement state and local patient evacuation efforts  during Hurricane Katrina and Hurricane Rita, which struck the Gulf Coast  several weeks after Hurricane Katrina. NDMS officials told us that  Hurricane Katrina was the first time that the patient evacuation and  definitive care components of NDMS were used for a large number of  patients. In response to state requests for assistance, NDMS moved people  from Louisiana after Hurricane Katrina and from Texas before Hurricane  Rita. In total, about 2,900 people were transported to NDMS patient  reception areas due to the two hurricanes.
section_title: Regulation of Hospitals and Nursing Homes
paragraphs: CMS establishes federal regulations that hospitals and nursing homes must  meet to participate in the Medicare and Medicaid programs. These  regulations relate to many aspects of hospital or nursing home operations,  such as health care services, dietetic services, and physical environment,  including emergency management. Hospitals that are accredited by  JCAHO or AOA are generally deemed to meet most of these Medicare and  Medicaid requirements; no organizations have similar deeming authority  for nursing homes. State agencies survey and certify nursing homes and  nonaccredited hospitals to ensure that they follow CMS requirements.  CMS provides guidance to state agencies in the CMS State Operations  Manual, which includes interpretive guidelines and survey procedures for  state agencies to assess compliance with CMS regulations. In addition to  CMS requirements, JCAHO, AOA, and states can establish additional  requirements for hospitals and nursing homes.
section_title: Federal Reports on Health Care Facility Evacuation Due to Hurricane Katrina
paragraphs: A number of federal reports address the issue of evacuation and health  care facility disaster planning. These reports have in various ways called  for improvements in coordination. The White House report on lessons  learned from the federal response to Hurricane Katrina recommended that  agencies coordinate together to plan, train, and conduct exercises to  evacuate patients when state and local agencies are unable to do so in a  timely or effective manner. The House of Representatives Select  Bipartisan Committee to Investigate the Preparation for and Response to  Hurricane Katrina reported that medical care and evacuations suffered  from a lack of advance preparations, inadequate communications, and  difficulties in coordinating efforts. The select committee’s report and a  DHS Office of Inspector General Performance Review of the Federal  Emergency Management Agency (FEMA) both noted that search and  rescue efforts during Hurricane Katrina were effective but could have  benefited from improved coordination among federal agencies. The  Senate Committee on Homeland Security and Governmental Affairs  reported that federal agencies involved in providing medical assistance did  not have adequate resources or the right medical capabilities to fully meet  the medical needs arising from Katrina, such as meeting the needs of large  evacuee populations, and were forced to use improvised and unproven  techniques to meet those needs. Further, the committee reported that the  federal government’s medical response suffered from a lack of planning,  coordination, and cooperation.
section_title: Facility Administrators Faced Several Challenges Related to Evacuation, Including Deciding Whether to Evacuate, Securing Transportation, and Maintaining Communication
paragraphs: Hospital and nursing home administrators faced several challenges related  to evacuation during recent hurricanes, including deciding whether to  evacuate or stay in their facilities and “shelter in place”, obtaining  transportation necessary for evacuations, and maintaining communication  outside of their facilities. Administrators said they generally prefer to  shelter in place, and when doing so must have the resources needed to  provide care during a hurricane, and maintain self-sufficiency immediately  after a hurricane to continue to care for patients until help can arrive.  When evacuations were needed, facility administrators said that they had  problems with transportation. Facilities had contracts with transportation  companies, but competition for the same pool of vehicles created supply  shortages. In addition, communication was impaired by damage to local  infrastructure as a result of the hurricanes. For example, a nursing home  in Florida was unable to communicate with local emergency managers.
subsections: section_title: Facility Administrators Faced Challenges in Deciding Whether to Evacuate or Shelter in Place
paragraphs: Hospital and nursing home administrators told us that they faced  challenges in deciding whether to evacuate, including ensuring that they  had sufficient resources to provide care or other services during the  disaster and then in its aftermath until assistance could arrive.  Administrators told us that they evacuate only as a last resort and that  facilities’ emergency plans are designed primarily to shelter in place. Some  hospitals provided a safe haven for devastated communities after a  hurricane. In addition, some hospitals saw a surge in the number of people  seeking care as a result of injuries sustained during the hurricane. For  example, clinicians at a 153-bed hospital in Mississippi treated  approximately 500 patients per day in the days after Hurricane Katrina, a  substantial increase from their normal workload of about 130 patients per  day. This hospital’s administrators told us that they felt obligated to  remain open to serve the community’s needs. In addition, facility  administrators and county representatives that we interviewed agreed that  sheltering in place is generally safer than evacuating vulnerable hospital  patients and nursing home residents. Although state and local  governments can issue mandatory evacuation orders for certain areas,  health care facilities may be exempt from these orders, as they were in a  Mississippi county for Hurricane Katrina. When preparing to shelter in  place, hospital administrators told us that they discharge patients when  possible and stop performing elective surgeries to reduce the number of  patients in the hospital.
In anticipation of an inability to replenish resources during a hurricane,  hospital and nursing home administrators take steps before hurricanes to  ensure that the facilities have the resources needed to shelter in place and  adequately care for patients and residents, including sufficient supplies,  food, water, and power. For example, a nursing home administrator in  Florida told us that the facility prepared for Hurricane Charley by  obtaining 10 days of food and water for its 120 residents plus additional  Meals, Ready-to-Eat to feed 500 people for up to 4 days, including staff  and their families. Administrators from a hospital told us that they call  their vendors 72 hours before a hurricane to order bulk supplies of milk,  bread, and paper goods. Administrators from a Mississippi hospital noted  that they prepare for hurricanes by ensuring that the facility has 3-4 days  of clean linens and 5-6 days of medical supplies. Administrators must also  make sure they have sufficient backup electrical power because life  support systems require electricity to operate. One hospital administrator  acquired an additional generator to extend the hospital’s capacity to  supply backup power to 10 days. In addition, many of the administrators  we interviewed noted that they maintain large fuel tanks to power the  generators. For example, one hospital maintained a 20,000 gallon tank,  which holds enough fuel to run the facility’s generators for 1 week. Some  administrators told us that they also had difficulty obtaining sufficient fuel  after the hurricanes.
In addition to obtaining tangible supplies, administrators face the  challenge of ensuring that facilities have the staff needed to provide  adequate patient care during and after a hurricane. Hospital administrators  noted the challenges involved with having sufficient numbers of clinical  staff, such as doctors, available during hurricanes. Some facility  administrators we interviewed identified “storm teams” of staff that were  required to report to the facility before a hurricane and remain on site  during the event. One hospital required the “storm team” to be prepared to  stay at the facility for 3-4 days. Staff members were required to bring  clothes, bedding, snacks, and other personal items. In some cases,  facilities also allowed these staff members to bring their families and pets.  One hospital administrator in Mississippi noted that the severity and  destruction caused by Hurricane Katrina prevented the relief staff from  taking over and the “storm team” remained at the facility for 14 days.  Another hospital administrator in Florida noted that after Hurricane  Charley, relief staff did not report for work.
Hospital and nursing home administrators we interviewed reported that  their facilities needed to be self-sufficient for a period of time immediately  after a hurricane because new supplies may not arrive for several days.  For example, a representative of a Florida nursing home association said  that facilities need at least 10 days of supplies to effectively shelter in  place until help can arrive. The need to be self-sufficient is especially  important when disasters affect entire communities and delay response  efforts, as demonstrated during hurricanes Charley and Katrina. Facilities  that were part of networks were able to call on their corporate offices or  sister facilities outside of the affected area to replenish needed supplies  after a hurricane. For example, one administrator said that the company  that owns his hospital has a division that tracks each facility’s  preparedness resources, and the company’s supply warehouse has  “disaster packs” of necessary supplies ready to be deployed in case of  emergency. Additionally, the company has large contracts in place so that  it can quickly obtain resources like fuel, generators, and staff.
section_title: Facility Administrators Had Problems Related to Transportation for Patient Evacuations
paragraphs: Facility administrators noted that they were not always able to obtain  appropriate vehicles to accommodate their facilities’ patient needs. While  some people can be moved using buses, some may require wheelchair- accessible vehicles, and others may need to be transported by ambulance.  For example, one nursing home administrator noted that the facility  contracted with a bus company, but stated that transportation remained a  challenge because most of the facility’s residents used electric wheelchairs  and needed vehicles with power lifts, which were not available. In  addition, facilities also needed trucks to move staff and supplies to care  for the patients. For example, one Florida nursing home administrator  noted that the facility had arrangements with a trucking company to load  and transport patient medical records, medications, laundry supplies,  food, and water. Another nursing home administrator in Mississippi said  that he rented a truck to move mattresses and other supplies for his  residents.
Having a contract with a transportation company or relying on the local  government did not guarantee availability of transportation resources  during a hurricane. Although facility administrators reported having  contracts with transportation companies, competition for the same pool of  vehicles created supply shortages. Hospital and nursing home  administrators in several communities told us that their transportation  companies also had contracts with other facilities in the community to  provide services, a situation that may be sufficient for small evacuations  but did not work when there were multiple facilities from the same area  that needed to evacuate. In addition to contracting with multiple facilities,  some companies’ vehicles were unavailable due to advance notice  requirements, and others may have had vehicles that were badly damaged  by the hurricane. For example, one nursing home administrator said that  the bus company his facility contracted with required 24-hours notice  before a bus could be chartered, and that providing this notice was  difficult in a disaster situation. Some facilities relied upon local  government resources to provide assistance with evacuations, but when  an entire community was severely affected, local ambulances were  damaged or in short supply and therefore unavailable. For example, one  Florida hospital administrator had arranged for transportation through the  local emergency operations center (EOC), but the hurricane destroyed the  EOC. In contrast, when local officials in Mississippi faced a shortage of  ambulances immediately after Hurricane Katrina, they called upon a  national ambulance company, with which they had a contract, to provide  additional resources from Texas and Alabama. Officials noted that state  resources were not available after the storm and contracting with an  ambulance company with national resources was beneficial.
section_title: Facility Administrators Faced Communication Challenges Due to Damage to Local Infrastructure Caused by Hurricanes
paragraphs: Hurricanes Charley and Katrina caused significant damage to the  infrastructure of the surrounding communities, and left some hospital and  nursing home administrators unable to communicate outside of their  facilities. Several administrators that we interviewed reported that land- based telephone lines were not functional and cellular telephone reception  was sporadic. Some administrators reported that cell phones based in  other areas were more reliable than local cell phones. Since the 2004  hurricane season, some facilities in Florida have purchased satellite  phones. For example, one nursing home administrator who faced  communications difficulties after Hurricane Charley has since purchased  satellite phones. However, during Hurricane Katrina, some Mississippi  hospital administrators told us that their satellite phones did not function.  Because no single communications technology is universally reliable,  some facility administrators told us that they plan to diversify their  communication capabilities by utilizing multiple forms of communication.
Communication problems also affected county officials. Local EOC  officials in both Mississippi and Florida reported being unable to  communicate with state officials or local health care facilities. Because of  communication problems at the local EOC, one nursing home  administrator in Florida asked a staff member to drive to the EOC to  communicate in person. In Mississippi, emergency managers relied on  handheld radios and personal contact to communicate immediately after  the hurricane. We have previously reported on communication difficulties  during a public health emergency.
section_title: NDMS Has Two Limitations That Constrain Its Assistance to State and Local Governments with Patient Evacuation and Which Are Not Addressed Elsewhere in the NRP
paragraphs: NDMS has two limitations in its design that constrain its assistance to  state and local governments with patient evacuation. First, NDMS is not  designed to move patients or residents out of hospitals or nursing homes  to mobilization centers. Second, NDMS was not designed nor is it  currently configured for people who do not need hospital care, including  nursing home residents.
The first limitation of NDMS is that it is designed to move patients from a  mobilization center, such as an airport, to other locations where they can  receive necessary medical care, but it is not designed to move patients or  residents out of hospitals or nursing homes to mobilization centers. NDMS  officials told us that transportation from a health care facility to an NDMS  mobilization center is the responsibility of local and state governments.  Moreover, NDMS does not include helicopters, ambulances, or other  short-distance vehicles necessary to move patients out of hospitals or  nursing homes to mobilization centers. NDMS officials stated that NDMS  transportation assets typically are large DOD airplanes designed to travel  long distances, which can take approximately 24 hours or more to arrange.  In addition, NDMS officials told us that to obtain ambulance or helicopter  service, they would contract with private providers near a disaster site,  which could lead to competition between the federal government and  state and local authorities for the same pool of limited resources.
Although NDMS evacuation efforts begin at mobilization centers, federal  officials told us that no federal program is designed to move patients or  residents out of hospitals or nursing homes to mobilization centers. NDMS  and other documents that we reviewed also do not identify other federal  programs that might assist in performing this function. We reviewed the  NRP, the September 2005 draft Catastrophic Incident Supplement to the  NRP, and NDMS documents. They do not indicate how the federal  government is to assist state and local authorities in moving hospital  patients and nursing home residents from their facilities. In particular, the  September 2005 draft Catastrophic Incident Supplement to the NRP,  which is intended to be used with the Catastrophic Incident Annex when a  catastrophic incident almost immediately overwhelms the capabilities of  state and local governments, states that collecting and transporting  patients from health care facilities to mobilization centers is the  responsibility of state and local authorities. The draft supplement does not  describe what, if any, role the federal government may play in  coordinating with state and local authorities for this kind of  transportation.
Despite this limitation of NDMS, some federal assistance was provided to  move people out of health care facilities during Hurricane Katrina. Coast  Guard officials told us that they evacuated about 9,400 people from  hospitals and nursing homes as part of their search and rescue operations.  NDMS officials reported that private, local, state, and federal resources  transported hospital patients and nursing home residents to mobilization  points, but there was a lack of coordination. For example, a report  prepared by NDMS officials after Hurricane Katrina noted that, initially,  transportation resources from the Coast Guard and DOD were not  coordinated.
The second limitation is that NDMS was not designed nor is it currently  configured for people who do not need hospital care, including nursing  home residents. As stated in the memorandum of agreement among the  NDMS federal partners, the patient evacuation function of NDMS is  intended to move patients so that they can receive medical care in NDMS  hospitals—typically nonfederal hospitals that have agreements with  NDMS. NDMS officials told us that they do not have agreements with  nursing homes or other types of health care providers. However, because  of the immediate demands posed by Hurricane Katrina, federal officials  told us that NDMS had to move people who did not need hospital care,  including nursing home residents and members of the general public who  arrived at NDMS mobilization centers. NDMS flights evacuated people  with various needs from mobilization centers to NDMS patient reception  areas where officials assessed their health needs and arranged for them to  receive additional medical care through the definitive care portion of  NDMS. NDMS reception areas had to make special arrangements for  people in need of nursing home care, because NDMS lacked preexisting  agreements with nursing homes equipped to handle people with  nonhospital health care needs. In a report prepared by NDMS after the  hurricane, federal officials noted that NDMS was not optimally prepared to  manage the nursing home requirements of evacuees who did not require  hospitalization. The movement of nursing home residents during  evacuations is not addressed elsewhere in the NRP.
section_title: Federal Requirements for Hospitals and Nursing Homes Include Provisions for Having Disaster Plans and Transferring Patients Out of Hospitals
paragraphs: At the federal level, CMS has requirements related to hospital and nursing  home disaster and evacuation planning as a condition of participation in  the Medicare and Medicaid programs. For hospitals, a CMS requirement  states that the overall hospital environment must be maintained to assure  the safety and well-being of patients. According to CMS guidelines for  interpreting this regulation, hospitals must develop and maintain  comprehensive emergency plans, and when developing plans, should  consider the transfer of patients to other health care settings or hospitals if  necessary. For nursing homes, a CMS regulation states that facilities must  have plans to meet all potential emergencies and disasters, although the  interpretative guidelines do not specifically mention transfer of residents.  CMS officials told us that, based on experiences during Hurricane Katrina,  they have established a work group within CMS to review hospital and  nursing home requirements and other provider standards, policies, and  guidance related to emergency preparedness, including issues related to  evacuations. The officials told us that they expect the work group to make  initial recommendations for improvement in 2006. (See app. II for CMS  regulations and interpretive guidelines related to evacuation planning and  emergency preparedness.)
In addition to CMS requirements, JCAHO, AOA, and states can establish  additional emergency management requirements for health care facilities.  For hospitals that it accredits, JCAHO requires that emergency plans  include provisions for evacuating the entire building and transporting  patients, supplies, staff, and equipment to alternate care sites if  necessary. AOA requires that emergency plans for hospitals that it  accredits include provisions for transferring patients and supplies to other  settings for health care if necessary. (See app. III for a list of JCAHO and  AOA requirements related to evacuation planning and emergency  preparedness.) States can also establish additional requirements for  facility evacuation planning that relate to transportation. For example,  Florida requires hospitals and nursing homes to have comprehensive  emergency management plans that document transportation arrangements  to be used to evacuate residents. Mississippi requires nursing homes to  maintain written transfer agreements with other facilities or alternative  shelters in the event of a disaster. The state also requires hospitals to  have written disaster preparedness plans that include relocation  arrangements, including transportation arrangements, in the event of an  evacuation.
section_title: Conclusions
paragraphs: Federal requirements for hospitals and nursing homes include provisions  that the facilities plan for disasters and emergencies. However, when  hurricanes Charley and Katrina hit the Gulf Coast area, they created  significant challenges for health care facility administrators that faced  evacuation, including deciding whether to evacuate, securing  transportation, and maintaining communications outside of their facilities.  In particular, securing transportation was challenging because when  multiple health care facilities within a community decided to evacuate,  they had difficulty obtaining the number and type of vehicles needed and  competed with each other for a limited supply of vehicles.
A federal role related to evacuation is described in various documents,  including the NDMS memorandum of agreement, the NRP, and its draft  Catastrophic Incident Supplement. However, the challenges faced by  hospitals and nursing homes during hurricanes Charley and Katrina also  revealed two limitations in the federal government’s support to health care  facilities that have to evacuate—the lack of assistance to states and  localities to move people out of health care facilities to a mobilization  point for federal transportation support and the lack of attention to  nursing home residents needing evacuation. In terms of the first limitation,  we found that the reliance in the NDMS design on local and state  resources to move people directly out of facilities is inadequate when  multiple facilities in the community have to evacuate simultaneously and  compete for too few vehicles. In addition, DHS’s draft Catastrophic  Incident Supplement to the NRP, which is intended to offer guidance for a  situation in which state and local resources are overwhelmed, also would  leave responsibility for moving people out of health care facilities on state  and local authorities. It does not describe the role the federal government  may play in coordinating with state and local authorities during hospital  and nursing home evacuations. In terms of the second limitation, we noted  that the evacuation of nursing home residents was not considered when  NDMS was originally designed in 1984—nor is it currently addressed  elsewhere in the NRP—but the experiences of these recent hurricanes also  showed that the needs of this population when evacuations are required  have been overlooked in the federal plans.
DHS is the lead agency responsible for issuance and maintenance of the  NRP, development of the draft Catastrophic Incident Supplement, and  activation of NDMS. Until it addresses these limitations—within NDMS,  the NRP, or through other mechanisms—vulnerabilities in the evacuation  of hospitals and nursing homes will continue, and the federal  government’s response will not be as effective as possible.
section_title: Recommendations for Executive Action
paragraphs: To address limitations in how the federal government provides assistance  with the evacuation of health care facilities, we recommend that the  Secretary of Homeland Security take the following two actions:    Clearly delineate how the federal government will assist state and local  governments with the movement of patients and residents out of hospitals  and nursing homes to a mobilization center where NDMS transportation  begins.  In consultation with the other NDMS federal partners—the Secretaries of  Defense, Health and Human Services, and Veterans Affairs—clearly  delineate how to address the needs of nursing home residents during  evacuations, including the arrangements necessary to relocate these  residents.
section_title: Agency Comments and Our Evaluation
paragraphs: We received written comments on a draft of this report from DHS, DOD,  HHS, and VA.
DHS stated that it will take our recommendations under advisement as it  reviews the National Response Plan. According to DHS, all of the NDMS  federal partners are currently reviewing the NDMS memorandum of  agreement with a view towards working with state and local partners to  alter, delineate, and otherwise clarify roles and responsibilities as  appropriate. DHS confirmed that the primary responsibility for  evacuations remains with state and local governments and that the federal  government becomes involved only when the capabilities of the state and  local governments are overwhelmed. However, as stated in the draft  report, neither NDMS documents, the NRP, nor the draft Catastrophic  Incident Supplement to the NRP—to be used in cases when the  capabilities of state and local governments are almost immediately  overwhelmed—describe the federal role in coordinating with state and  local authorities during hospital and nursing home evacuations. We also  noted that reliance on state and local resources was inadequate when  multiple facilities in a community had to evacuate simultaneously. DHS’s  written comments are reprinted in appendix IV.
DOD disagreed with our conclusions concerning NDMS’s two limitations.  First, DOD stated that our report implies that the provision of short- distance transportation is a federal responsibility, but DOD maintains that  it is a state and local responsibility. However, during a catastrophic  incident, the capabilities of state and local governments may almost  immediately become overwhelmed. As we stated above in our response to  DHS’s comments, the federal role in these situations has not been  described. Second, DOD stated that our conclusion regarding the needs of  nursing home residents was technically correct, but that we failed to  describe the successful evacuation of nursing home residents during  Hurricane Rita. Our draft report did describe NDMS’s evacuation of  people, including nursing home residents and other people who did not  need hospital care, during recent hurricanes due to the immediate  demands posed by the storms. However, we also noted that the NDMS  after-action report on hurricanes Katrina and Rita states that NDMS was  not optimally prepared to manage the nursing home requirements of  evacuees who did not require hospitalization. For this reason, we believe  that explicit consideration of the needs of nursing home residents is  warranted. DOD’s written comments are reprinted in appendix V.
HHS concurred with our recommendations and made two general  comments. First, HHS noted that we should address the role of DOT in the  NRP to provide transportation support for domestic emergencies. Under  ESF #8, DOT can assist with identifying and arranging for all types of  transportation. However, as stated in the draft report, the NRP does not  indicate how DOT or other federal agencies are to assist state and local  authorities in moving hospital patients and nursing home residents from  their facilities. Second, HHS commented that the report does not describe  why NDMS was designed to focus on hospital evacuation, but HHS did not  provide any additional information about NDMS’s origins. Although the  draft report included available information on the origins of NDMS, our  assessment focused on the program’s current status. HHS’s written  comments are reprinted in appendix VI.
VA agreed with our conclusions and recommendations and stated that it  would continue to address issues raised in the draft report. VA’s written  comments are reprinted in appendix VII.
DHS and HHS also provided technical comments. In addition, DOT  provided technical comments via email. We incorporated these comments  where appropriate.
We are sending copies of this report to the Secretaries of DOD, HHS, DHS,  DOT, VA, and other interested parties. We will also make copies available  to others on request. In addition, the report will be available at no charge  on GAO’s Web site at http://www.gao.gov.
If you or your staff have any questions about this report, please contact me  at (202) 512-7101 or bascettac@gao.gov. Contact points for our Offices of  Congressional Relations and Public Affairs may be found on the last page  of this report. GAO staff who made major contributions to this report are  listed in appendix VIII.
section_title: Appendix I: Scope and Methodology
paragraphs: To examine the challenges hospital and nursing home administrators  faced related to recent hurricanes, we conducted case studies in two  states—Florida and Mississippi. We selected these states based on their  experience with previous disasters. During 2004, the state of Florida was  hit by four hurricanes—Charley, Frances, Ivan, and Jeanne. Hurricane  Charley was the strongest of these four, and the strongest hurricane to hit  the United States since Hurricane Andrew hit southern Florida in 1992. In  2005, Mississippi received heavy storm damage from Hurricane Katrina  caused by wind and an extremely high storm surge.
In Florida, to understand the role of the state and local governments in  evacuating hospitals and nursing homes, we interviewed and obtained  documents from state and county officials. At the state level, we  interviewed officials from the Florida Department of Health’s Office of  Emergency Operations. We reviewed the Florida Comprehensive  Emergency Management Plan, as well as Florida’s after-action report for  the 2004 Hurricane season. At the local level, we selected two counties  affected by Hurricane Charley—Charlotte and Volusia counties. Charlotte  County, the entry point for the hurricane, is located on the Gulf Coast of  Florida. Volusia County, the exit point for the hurricane, is located on the  Atlantic Coast of the state. Within each county, we interviewed emergency  management officials and reviewed county emergency management plans.
To obtain information on the experiences of individual health care  facilities in Florida, we identified hospitals and nursing homes within each  of the selected counties, interviewed facility administrators, and reviewed  documents. To select facilities, we asked emergency management officials  in each county to provide contact information for hospitals and nursing  homes that either evacuated or sheltered in place due to Hurricane  Charley. In cases where the representatives identified by county officials  were unavailable, we selected alternate health care facilities based on  their proximity to the ocean. For each facility, we obtained and reviewed  applicable emergency plans, hurricane plans, and/or evacuation plans. In  total, we interviewed administrators from two hospitals and two nursing  homes in Charlotte County and one hospital and two nursing homes in  Volusia County. In addition to facility administrators, we interviewed  officials from the Florida Hospital Association, the Florida Association of  Homes for the Aging, and the Florida Health Care Association.
In Mississippi, to understand the role of the state and local governments in  evacuating hospitals and nursing homes, we interviewed and obtained  documents from state and county officials. At the state level, we  interviewed officials from the Mississippi Emergency Management Agency  and Department of Health, and reviewed documents including the  Mississippi Comprehensive Emergency Management Plan. At the local  level, we selected the two coastal counties that were hit most directly by  Hurricane Katrina—Hancock and Harrison counties. Hancock County,  which includes the cities of Waveland and Bay St. Louis, was directly in  the path of the storm and sustained extensive damage. Harrison County,  which is adjacent to Hancock County and includes the cities of Gulfport  and Biloxi, sustained extensive damage and has the area’s largest  population. In each county, we interviewed emergency management  officials. We also reviewed emergency management plans from Hancock  and Harrison counties.
To obtain information on the experience of individual health care facilities  in Mississippi, we identified hospitals, nursing homes, and assisted living  facilities within each of the selected counties; interviewed facility  administrators; and reviewed documents provided. To locate health care  facilities, we relied on a list of hospitals, nursing homes, and assisted living  facilities in Hancock and Harrison counties from a June 2005 Mississippi  Department of Health report on hospitals and a September 2005  Mississippi Department of Health report on institutions for the aged or  infirm. We also identified facilities in Harrison County that were operated  by the Department of Veterans Affairs (VA). We excluded nursing homes  with fewer than 20 licensed beds. From this list, we selected facilities  based on ownership type, vulnerability and proximity to the ocean, and  size. For each facility, we obtained and reviewed emergency plans,  hurricane plans, and/or evacuation plans. In total, we interviewed officials  from one hospital and one nursing home in Hancock County and four  hospitals and two assisted living facilities in Harrison County. We also  interviewed representatives from the Gulf States Association of Homes  and Services for the Aging.
To examine the extent to which limitations exist in the design of the  National Disaster Medical System (NDMS) or other federal programs to  assist state and local governments with patient evacuations, we reviewed  federal documents such as the National Response Plan, including  Emergency Support Function #8—Public Health and Medical Services— and the Catastrophic Incident Annex. We also obtained and reviewed a  September 2005 draft of the Catastrophic Incident Supplement to the NRP.  We interviewed emergency preparedness officials from the Department of  Defense, the Department of Health and Human Services, the Department  of Homeland Security, the Department of Transportation, and the VA. To  obtain additional information on NDMS, we reviewed program documents,  including the memorandum of agreement that governs NDMS and an after- action report on the use of NDMS due to Hurricane Katrina.
To examine the federal requirements for hospital and nursing home  disaster and evacuation planning, we reviewed documents that identify the  federal requirements and national standards related to emergency  management, disaster preparedness, and patient evacuation. We reviewed  documents provided by the Centers for Medicare & Medicaid Services  (CMS) and by accrediting organizations that assess compliance with CMS  requirements—the Joint Commission on Accreditation of Healthcare  Organizations and the American Osteopathic Association. We also  interviewed officials from these organizations concerning the  requirements and enforcement mechanisms, as well as officials from the  American Hospital Association, Federation of American Hospitals, and the  American Health Care Association. In addition, we interviewed and  obtained documents from the Florida Agency for Health Care  Administration officials responsible for the licensing and certification of  health care facilities as well as officials from the Mississippi Department  of Health. We performed our work from October 2005 through July 2006 in  accordance with generally accepted government auditing standards.
section_title: Appendix II: CMS Regulations and Interpretive Guidelines Related to Hospital and Nursing Home Disaster and Evacuation
paragraphs: The Centers for Medicare & Medicaid Services (CMS) establishes federal  regulations that hospitals and nursing homes must meet to participate in  the Medicare and Medicaid programs. CMS’s interpretive guidelines  contain authoritative interpretations and clarifications of statutory and  regulatory requirements and are to be used to make determinations about  compliance with requirements. The tables below include regulations for  hospitals and nursing homes that relate to disaster and evacuation  planning. Table 1 includes CMS regulations and interpretive guidelines for  hospitals.
Table 2 includes CMS regulations and interpretive guidelines for nursing  homes. CMS surveyors conduct health care facility surveys to evaluate the  manner and degree to which the providers satisfy various CMS  requirements or standards. Long-term care facilities include nursing  homes.
section_title: Appendix III: JCAHO and AOA Requirements for Hospital Evacuation Planning and Emergency Preparedness
paragraphs: Hospitals that are accredited by the Joint Commission on Accreditation of  Healthcare Organizations (JCAHO) or the American Osteopathic  Association (AOA) are generally deemed to be compliant with the Centers  for Medicare & Medicaid Services requirements. The document and table  below include JCAHO and AOA requirements for hospitals that relate to  evacuation planning and emergency preparedness. The document includes  JCAHO hospital requirements, and table 3 includes AOA hospital  requirements.
section_title: Appendix IV: Comments from the Department of Homeland Security
section_title: Appendix V: Comments from the Department of Defense
section_title: Appendix VI: Comments from the Department of Health and Human Services
section_title: Appendix VII: Comments from the Department of Veterans Affairs
section_title: Appendix VIII: GAO Contact and Staff Acknowledgments
subsections: section_title: Acknowledgments
paragraphs: In addition to the contact named above, key contributors to this report  were Linda T. Kohn, Assistant Director; La Sherri Bush; Krister Friday;  Nkeruka Okonmah; and William Simerl.
section_title: Related GAO Products
paragraphs: Disaster Preparedness: Preliminary Observations on the Evacuation of  Vulnerable Populations due to Hurricanes and Other Disasters. GAO-06- 790T. Washington, D.C.: May 18, 2006.
Hurricane Katrina: Status of the Health Care System in New Orleans  and Difficult Decisions Related to Efforts to Rebuild It Approximately 6  Months After Hurricane Katrina. GAO-06-576R. Washington, D.C.:   March 28, 2006.
Hurricane Katrina: GAO’s Preliminary Observations Regarding  Preparedness, Response, and Recovery. GAO-06-442T. Washington, D.C.:  March 8, 2006.
Disaster Preparedness: Preliminary Observations on the Evacuation of  Hospitals and Nursing Homes Due to Hurricanes. GAO-06- 443R. Washington, D.C.: February 16, 2006.
HHS Bioterrorism Preparedness Programs: States Reported Progress but  Fell Short of Program Goals for 2002. GAO-04-360R. Washington, D.C.:  February 10, 2004.
Bioterrorism: Public Health Response to Anthrax Incidents of 2001.  GAO-04-152. Washington, D.C.: October 15, 2003.
Hospital Preparedness: Most Urban Hospitals Have Emergency Plans  but Lack Certain Capacities for Bioterrorism Response. GAO-03-924.  Washington, D.C.: August 6, 2003.
Bioterrorism: Information Technology Strategy Could Strengthen  Federal Agencies’ Abilities to Respond to Public Health Emergencies.  GAO-03-139. Washington, D.C.: May 30, 2003.
Bioterrorism: Preparedness Varied across State and Local Jurisdictions.  GAO-03-373. Washington, D.C.: April 7, 2003.