At the federal level, the NRP provides a framework for how the federal government is to assist states and localities in managing emergencies and major disasters. NDMS is one of the programs identified in the NRP that can supplement state and local medical resources during emergencies, including providing resources to assist with evacuation. At the individual facility level, hospitals and nursing homes must comply with CMS requirements to participate in the Medicare and Medicaid programs. Several recently issued federal reports have looked at the adequacy of health care facility disaster planning, as prompted by Hurricane Katrina. In December 2004, DHS issued the NRP to consolidate existing federal government emergency response plans into a single coordinated plan, as mandated by the Homeland Security Act of 2002. 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. 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. 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. 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. Hospital and nursing home administrators faced several challenges related to evacuation during recent hurricanes, including deciding whether to evacuate or stay in their facilities and “shelter in place”, obtaining transportation necessary for evacuations, and maintaining communication outside of their facilities. Administrators said they generally prefer to shelter in place, and when doing so must have the resources needed to provide care during a hurricane, and maintain self-sufficiency immediately after a hurricane to continue to care for patients until help can arrive. When evacuations were needed, facility administrators said that they had problems with transportation. Facilities had contracts with transportation companies, but competition for the same pool of vehicles created supply shortages. In addition, communication was impaired by damage to local infrastructure as a result of the hurricanes. For example, a nursing home in Florida was unable to communicate with local emergency managers. Hospital and nursing home administrators told us that they faced challenges in deciding whether to evacuate, including ensuring that they had sufficient resources to provide care or other services during the disaster and then in its aftermath until assistance could arrive. Administrators told us that they evacuate only as a last resort and that facilities’ emergency plans are designed primarily to shelter in place. Some hospitals provided a safe haven for devastated communities after a hurricane. In addition, some hospitals saw a surge in the number of people seeking care as a result of injuries sustained during the hurricane. For example, clinicians at a 153-bed hospital in Mississippi treated approximately 500 patients per day in the days after Hurricane Katrina, a substantial increase from their normal workload of about 130 patients per day. This hospital’s administrators told us that they felt obligated to remain open to serve the community’s needs. In addition, facility administrators and county representatives that we interviewed agreed that sheltering in place is generally safer than evacuating vulnerable hospital patients and nursing home residents. Although state and local governments can issue mandatory evacuation orders for certain areas, health care facilities may be exempt from these orders, as they were in a Mississippi county for Hurricane Katrina. When preparing to shelter in place, hospital administrators told us that they discharge patients when possible and stop performing elective surgeries to reduce the number of patients in the hospital. In anticipation of an inability to replenish resources during a hurricane, hospital and nursing home administrators take steps before hurricanes to ensure that the facilities have the resources needed to shelter in place and 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.