GAO
United States Government Accountability Office
Report to Congressional Committees
DISASTER
PREPAREDNESS
Limitations in Federal
Evacuation Assistance
for Health Facilities
Should be Addressed
GAO-06-826
July 2006
G A O
Accountability Integrity Reliability
Highlights
Highlights of GAO-06-826, a report to
congressional committees
DISASTER PREPAREDNESS
Limitations in Federal Evacuation
Assistance for Health Facilities Should be
Addressed
Why GAO Did This Study
Hurricane Katrina demonstrated
difficulties involved in evacuating
communities and raised questions
about how hospitals and nursing
homes plan for evacuations and
how the federal government
assists. Due to broad-based
congressional interest, GAO
assessed the evacuation of hospital
patients and nursing home
residents. Under the Comptroller
General's authority to conduct
evaluations on his own initiative,
GAO examined (1) the challenges
hospital and nursing home
administrators faced, (2) the extent
to which limitations exist in the
design of the National Disaster
Medical System (NDMS) to assist
with patient evacuations, and
(3) the federal requirements for
hospital and nursing home disaster
and evacuation planning. GAO
reviewed documents and
interviewed federal officials, and
interviewed hospital and nursing
home administrators and state and
local officials in areas affected by
Hurricane Katrina in Mississippi
and Hurricane Charley in Florida.
What GAO Recommends
GAO recommends that DHS clearly
delineate (1) how the federal
government will assist state and
local governments with the
transportation of patients and
residents out of hospitals and
nursing homes, and (2) how to
address the needs of nursing home
residents during evacuations. In its
comments, DHS stated that it will
take the recommendations under
advisement as it revises the NRP.
www.gao.gov/cgi-bin/getrpt7GAO-06-826.
To view the full product, including the scope
and methodology, click on the link above.
For more information, contact Cynthia A.
Bascetta at (202) 512-7101 or
bascettac @ gao.gov.
What GAO Found
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.
United States Government Accountability Office
Contents
Letter
Results in Brief
Background
Facility Administrators Faced Several Challenges Related to
Evacuation, Including Deciding Whether to Evacuate, Securing
Transportation, and Maintaining Communication
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
Federal Requirements for Hospitals and Nursing Homes Include
Provisions for Having Disaster Plans and Transferring Patients
Out of Hospitals
Conclusions
Recommendations for Executive Action
Agency Comments and Our Evaluation
4
6
11
15
17
18
19
20
Appendix I
Scope and Methodology
24
Appendix II
CMS Regulations and Interpretive Guidelines
Related to Hospital and Nursing Home Disaster and
Evacuation
27
Appendix III
JCAHO and AOA Requirements for Hospital
Evacuation Planning and Emergency Preparedness
30
Appendix IV
Comments from the Department of Homeland
Security
44
Appendix V
Comments from the Department of Defense
46
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GAO-06-826 Evacuation of Hospitals and Nursing Homes
Appendix VI
Comments from the Department of Health and
Human Services
48
Appendix VII
Comments from the Department of Veterans Affairs
49
Appendix VIII
GAO Contact and Staff Acknowledgments
50
Related GAO Products
51
Tables
Table 1: CMS Regulation and Interpretive Guidelines for Hospitals
Table 2: CMS Guidance to Surveyors for Long Term Care Facilities
Table 3: 2005 AOA Accreditation Requirements for Hospitals
27
29
41
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GAO-06-826 Evacuation of Hospitals and Nursing Homes
Abbreviations
AOA
American Osteopathic Association
CMS
Centers for Medicare & Medicaid Services
DHS
Department of Homeland Security
DMAT
Disaster Medical Assistance Team
DOD
Department of Defense
DOT
Department of Transportation
EOC
emergency operations center
ESF
emergency support function
FEMA
Federal Emergency Management Agency
HHS
Department of Health and Human Services
JCAHO
Joint Commission on Accreditation of Healthcare
Organizations
NDMS
National Disaster Medical System
NRP
National Response Plan
QAPI
quality assessment performance improvement
VA
Department of Veterans Affairs
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GAO-06-826 Evacuation of Hospitals and Nursing Homes
i
^ G A O
— Accountability * Integrity * Reliability
United States Government Accountability Office
Washington, DC 20548
July 20, 2006
Congressional Committees
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. 1 Moreover, if administrators decide to
evacuate, hospital patients or nursing home residents may need special
equipment or have other complicating factors which inhibit their
movement, thereby increasing the risk to their safety during the
evacuation process. Due to Hurricane Katrina, efforts were made to
evacuate hospital patients and nursing home residents. In the storm's
aftermath, congressional reports raised questions about how health care
facility administrators plan for hurricanes, how they implement their
plans, and how the federal government assists health care facilities and
state and local governments with facility evacuations. 2
Federal, state, and local governments, as well as individual health care
facilities, have plans for how they will respond to emergencies such as
hurricanes. At the federal level, the National Response Plan (NRP) 3
provides a framework for how the federal government is to assist states
and localities in managing domestic incidents, including both incidents of
Vor our purposes, evacuation refers to moving all hospital patients or nursing home
residents out of both the facility and the affected area.
2 See U.S. House of Representatives, A Failure of Initiative: Final Report of the Select
Bipartisan Committee to Investigate the Preparation for and Response to Hurricane
Katrina (Feb. 15, 2006). See also Committee on Homeland Security and Governmental
Affairs, U.S. Senate, Hurricane Katrina: A Nation Still Unprepared (May 2006).
3 This report reflects the NRP as updated on May 25, 2006.
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GAO-06-826 Evacuation of Hospitals and Nursing Homes
national significance and those of lesser severity. 4 A program identified in
the NRP, the National Disaster Medical System (NDMS), can assist state
and local governments with evacuations of patients who need hospital
care. 5 NDMS is a partnership of four federal agencies, and the Department
of Homeland Security (DHS) is the lead agency. 6 At the state and local
levels, governments often have comprehensive emergency management
plans that mirror the NRP. At the individual facility level, hospitals and
nursing homes that participate in the Medicare and Medicaid programs
must comply with requirements established by the Department of Health
and Human Services' (HHS) Centers for Medicare & Medicaid Services
(CMS). 7 Compliance with these requirements is assessed by accrediting
organizations such as the Joint Commission on Accreditation of
Healthcare Organizations (JCAHO) and the American Osteopathic
Association (AOA), and state agencies.
Due to broad-based congressional interest, we assessed the evacuation of
hospital patients and nursing home residents due to hurricanes. We
performed this work under the Comptroller General's authority to conduct
evaluations on his own initiative. 8 In February 2006, we reported on
4 Under the NRP, the Secretary of Homeland Security will consider, but is not limited to, the
four criteria stated in Homeland Security Presidential Directive 5 (HSPD-5) when deciding
whether to declare an incident of national significance. These criteria are: (1) a federal
department or agency acting under its own authority has requested the assistance of the
Secretary of Homeland Security, (2) the resources of state and local authorities are
overwhelmed and federal assistance has been requested by the appropriate state and local
authorities, (3) more than one federal department or agency has become substantially
involved in responding to an incident, or (4) the Secretary of Homeland Security has been
directed to assume responsibility for managing a domestic incident by the President.
5 Public Health Security and Bioterrorism Preparedness and Response Act of 2002, Pub. L.
No. 107-188, § 102(a), 116 Stat. 595, 599 (formally establishing a program otherwise in
operation since 1984; to be codified at 42 U.S.C. § 300hh-ll).
6 The NDMS partners are DHS, Department of Health and Human Services (HHS),
Department of Veterans Affairs (VA), and Department of Defense (DOD). The Homeland
Security Act of 2002 transferred overall NDMS responsibility to DHS from HHS. Pub. L. No.
107-296, § 503(5), 116 Stat. 2135, 2213 (codified at 6 U.S.C. § 313(5)). H.R. 5438, 109th Cong.
(2006), which was introduced May 22, 2006, would transfer overall NDMS responsibility
back to HHS.
CMS issues interpretive guidelines that contain authoritative interpretations and
clarifications of statutory and regulatory provisions, and these are to be used to make
compliance determinations. Throughout this report, we refer to both CMS regulations and
interpretive guidelines as "requirements."
8 31 U.S.C. § 717(b)(1) (2000).
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GAO-06-826 Evacuation of Hospitals and Nursing Homes
preliminary observations from our work, 9 and in May 2006, we testified on
our preliminary observations before the Senate Special Committee on
Aging. 10 To complete our assessment, we examined (1) the challenges
hospital and nursing home administrators faced related to recent
hurricanes, (2) the extent to which limitations exist in the design of NDMS
or other federal programs to assist state and local governments with
patient evacuations, and (3) the federal requirements for hospital and
nursing home disaster and evacuation planning.
For our first objective related to the challenges hospital and nursing home
administrators faced related to recent hurricanes, we reviewed
documents, including emergency management plans from state and local
governments and hospitals and nursing homes in Florida and Mississippi.
We interviewed officials in Mississippi who experienced Hurricane
Katrina, including officials from five hospitals, three nursing homes and
assisted living facilities, state officials, and local emergency management
officials in two counties. We also interviewed officials in Florida in areas
that experienced hurricanes in 2004, particularly those affected by
Hurricane Charley, which was the strongest hurricane to hit the United
States since Andrew hit southern Florida in 1992. 11 In Florida, we spoke
with officials from three hospitals and three nursing homes, state officials,
and local emergency management officials in two counties. We also
interviewed officials from national hospital and nursing home
associations, Florida hospital and nursing home associations, and a
Mississippi nursing home association. For our second objective
concerning the extent to which limitations exist in the ability of NDMS or
other federal programs to assist state and local governments with patient
evacuations, we reviewed federal documents such as the NRP, including
the September 2005 draft Catastrophic Incident Supplement to the NRP.
We also interviewed officials from the Department of Defense (DOD),
HHS, DHS, the Department of Transportation (DOT), and the Department
of Veterans Affairs (VA), including officials who are responsible for NDMS,
GAO, Disaster Preparedness: Preliminary Observations on the Evacuation of Hospitals
and Nursing Homes Due to Hurricanes, GAO-06-443R (Washington, D.C.: Feb. 16, 2006).
Also see related GAO products at the end of this report.
10 GAO, 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 Charley struck the Gulf Coast of Florida on August 13, 2004. The hurricane
continued across Florida to exit the state on the Atlantic Coast on August 14, 2004.
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GAO-06-826 Evacuation of Hospitals and Nursing Homes
asking about moving patients out of facilities and out of the affected areas.
For our third objective on federal requirements for hospital and nursing
home disaster and evacuation planning, we reviewed CMS documents
describing hospital and nursing home emergency planning requirements
that specifically relate to evacuations. We also interviewed officials from
CMS, JCAHO, and AOA concerning these requirements, as well as officials
from national hospital and nursing home associations, Florida hospital and
nursing home associations, and a Mississippi nursing home association. In
addition, we interviewed officials and obtained documents from the
Florida Agency for Healthcare Administration and Mississippi Department
of Health concerning state hospital and nursing home requirements for
evacuation. For additional information on our scope and methodology, see
appendix I. Our work was performed from October 2005 through July 2006
in accordance with generally accepted government auditing standards.
RGSllltS in Brief Hospital and nursing home administrators faced several challenges related
to evacuations during recent hurricanes, including deciding whether to
evacuate or stay in their facilities and "shelter in place", obtaining
transportation necessary for evacuations, and maintaining communication
outside of their facilities. Administrators said they generally prefer to
shelter in place, but when doing so they must have sufficient resources to
provide care during a hurricane, and maintain self-sufficiency immediately
after a hurricane to continue to care for patients until help can arrive. For
example, during hurricanes Katrina and Charley, administrators had to
ensure that their facilities had needed resources, including staff who could
stay at the facility for 3 or more days; sufficient food, water, and supplies
to account for the inability to replenish resources during the hurricane;
and power, which required having enough fuel to run generators for
multiple days. When evacuations were needed, facility administrators said
that they had problems with transportation, such as securing the vehicles
needed to evacuate patients. Although facilities had contracts with
transportation companies, competition for the same pool of vehicles
created supply shortages. In addition, communication was impaired by
hurricane damage to the local infrastructure. For example, a nursing home
in Florida was unable to communicate with local emergency managers.
NDMS has two limitations in its design that constrain its assistance to
state and local governments with patient evacuation, and which are not
addressed elsewhere in the NRP. The first limitation is that NDMS
evacuation efforts begin at a mobilization center, such as an airport, and
do not include short-distance transportation assets, such as ambulances or
helicopters, to move patients out of health care facilities to mobilization
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GAO-06-826 Evacuation of Hospitals and Nursing Homes
centers. Moreover, based on the documents we reviewed, including the
NRP, we found that there are no other federal programs that assist with
this transportation function. The second limitation is that NDMS supports
the evacuation of patients needing hospital care; the program was not
designed nor is it currently configured to move people who do not require
hospitalization, such as nursing home residents. Although NDMS moved
nursing home residents during Hurricane Katrina who were brought to
mobilization centers, NDMS officials had to make special arrangements for
people in need of nursing home care because NDMS lacked preexisting
agreements with nursing homes. The movement of nursing home residents
during evacuations is not addressed elsewhere in the NRP.
At the federal level, CMS has requirements related to hospital and nursing
home disaster and evacuation planning as a condition of participation in
the Medicare and Medicaid programs. For hospitals, CMS requires that the
overall hospital environment must be maintained to assure the safety and
well-being of patients. According to CMS guidelines for interpreting this
regulation, hospitals must develop and maintain comprehensive
emergency plans, and when developing plans, should consider the transfer
of patients to other health care settings or hospitals if necessary. For
nursing homes, CMS requires that facilities must have plans to meet all
potential emergencies and disasters, although CMS guidelines for
interpreting the regulation do not specifically mention transfer of
residents. In addition, JCAHO, AOA, and states can also have additional
emergency management requirements. For example, JCAHO requires that
hospitals it accredits have emergency plans that include provisions for
evacuating the entire building and transporting patients, supplies, staff,
and equipment to alternate care sites if necessary.
We are recommending that DHS clearly delineate how the federal
government will assist state and local governments with the transportation
of patients and residents out of hospitals and nursing homes to a
mobilization center where NDMS evacuation begins. We further
recommend that DHS, in consultation with the three other NDMS partners,
clearly delineate how to address the needs of nursing home residents
during evacuations, including the arrangements necessary to relocate
these residents.
We received written comments on a draft of this report from DHS, DOD,
HHS, and VA. DHS stated that it will take our recommendations under
advisement as it reviews the National Response Plan. According to DHS,
all of the NDMS federal partners are currently reviewing the NDMS
memorandum of agreement with a view toward working with state and
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GAO-06-826 Evacuation of Hospitals and Nursing Homes
local partners to alter, delineate, and otherwise clarify roles and
responsibilities as appropriate. HHS and VA generally agreed with our
recommendations. DOD disagreed with our conclusion regarding NDMS
limitations, noting that state and local governments are responsible for the
provision of short-distance transportation, rather than it being a federal
responsibility. However, DHS confirmed that while the primary
responsibility for evacuations remains with state and local governments,
the federal government becomes involved when the capabilities of the
state and local governments are overwhelmed, as we reported. We
therefore believe that it is important for DHS to clearly delineate how the
federal government will assist state and local governments in these
instances.
BcLCkSrOlind ^ ^ e ^ e( ^ era ^ l eve l> 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.
The National Response In December 2004, DHS issued the NRP to consolidate existing federal
Plan government emergency response plans into a single coordinated plan, as
mandated by the Homeland Security Act of 2002. 12 The NRP provides a
framework for how the federal government is to assist states and localities
in managing domestic incidents, including an "emergency" 13 or a "major
'Tub. L. No. 107-296, § 502(6), 116 Stat. 2135, 2212-13 (to be codified at 6 U.S.C. § 312(6)).
The NRP supersedes other federal emergency planning documents, including the Initial
National Response Plan and the Federal Response Plan.
13 An emergency is defined as any occasion or instance for which, in the determination of
the President, federal assistance is needed to supplement state and local efforts and
capabilities to save lives and to protect property and public health and safety, or to lessen
or avert the threat of a catastrophe in any part of the United States. 42 U.S.C. § 5122(1)
(2000).
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GAO-06-826 Evacuation of Hospitals and Nursing Homes
disaster" 14 declared by the President under the Robert T. Stafford Disaster
Relief and Emergency Assistance Act (Stafford Act). 15 On May 25, 2006,
DHS revised the NRP to address certain weaknesses or ambiguities
identified following Hurricane Katrina. 16
The NRP includes a Catastrophic Incident Annex, which provides for an
accelerated, proactive national response to catastrophic incidents —
defined as any natural or manmade incident, including terrorism, resulting
in extraordinary levels of mass casualties, damage, or disruption severely
affecting the population, infrastructure, environment, economy, national
morale, and/or government functions. 17 By definition, a catastrophic
incident almost immediately exceeds resources normally available to
state, local, tribal, and private-sector authorities in the impacted area. A
separate Catastrophic Incident Supplement, which was drafted but had
not been approved at the time of Hurricane Katrina, provides additional
detail on the roles and responsibilities of federal, state, and local
responders during catastrophic incidents. However, as of June 2006, the
supplement had not been finalized.
Among its many components, the NRP establishes 15 emergency support
functions (ESF), which identify resources and define the missions and
14 Major disaster is defined as any natural catastrophe or, regardless of cause, any fire,
flood, or explosion, in any part of the United States, which in the determination of the
President causes damage of sufficient severity and magnitude to warrant major disaster
assistance under the Stafford Act to supplement the efforts and available resources of
states, local governments, and disaster relief organizations in alleviating damage, loss,
hardship, or suffering. 42 U.S.C. § 5122(2) (2000).
15 Pub. L. No. 93-288, 88 Stat. 143 (1974) (codified as amended at 42 U.S.C. §§ 5121-5206).
The Stafford Act primarily establishes the programs and processes the federal government
uses to provide emergency and major disaster assistance to states, local governments,
tribal nations, individuals, and qualified private nonprofit organizations.
16 The revised NRP makes clear that the Secretary of Homeland Security is responsible for
declaring and managing incidents of national significance such as Hurricane Katrina.
Incidents of lesser severity requiring federal involvement are also subject to the NRP, but
implementation of the NRP is to be scaled and flexible depending on the nature of the
event.
17 The responsibility for determining whether an incident of national significance meets the
NRP's definition of a "catastrophic incident" rests with the Secretary of Homeland Security.
The Secretary makes a "catastrophic incident" designation to activate the provisions of the
annex. The Secretary declared Hurricane Katrina an incident of national significance on
August 30, 2005, but never declared it a catastrophic incident. The revised NRP makes
explicit that the Secretary could activate the annex to address events that are projected to
mature to catastrophic proportions, such as strengthening hurricanes.
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responsibilities of various federal agencies in helping coordinate support
during incidents of national significance. For each of the NRP's 15 ESFs,
which include Transportation, Communications, Firefighting, and Public
Health and Medical Services, the NRP designates a federal agency as the
ESF coordinator responsible for pre-incident planning and coordination. It
also designates one or more primary agencies to be responsible for
operational priorities and activities, coordinating with other agencies and
state partners, and planning for incident management. HHS, for example,
is designated as the ESF coordinator and the primary agency for ESF #8 —
Public Health and Medical Services.
The National Disaster NDMS, one of the programs included in ESF #8 — Public Health and
Medical System Medical Services — of the NRP, was formed in 1984 to care for massive
numbers of casualties generated in a domestic disaster or an overseas
conventional war. It is a nationwide medical response system to
supplement state and local medical resources during disasters and
emergencies and to provide back-up medical support to the military and
VA health care systems during an overseas conventional conflict. DOD,
HHS, DHS, and VA are federal partners in NDMS. These partners most
recently signed a memorandum of agreement in October 2005 that
describes the roles and responsibilities of each partner. DHS has the
authority to activate NDMS in response to public health emergencies,
which include, but are not limited to, presidentially declared emergencies
or major disasters under the Stafford Act.
NDMS consists of three key functions:
• medical response, which includes medical equipment and supplies, patient
triage, and other emergency health care services provided to disaster
victims at a disaster site through NDMS medical response teams such as
Disaster Medical Assistance Teams (DMAT); 18
• patient evacuation, which includes communication and transportation to
evacuate patients from a mobilization center near the disaster site, such as
an airport, to reception facilities in other locations; and
• "definitive care," which is additional medical care — beyond emergency
care — that begins once disaster victims are placed into an NDMS inpatient
A Disaster Medical Assistance Team (DMAT) is a group of medical and support personnel
designated to provide medical care during disasters. DMATs are designed to deploy to
disaster sites with sufficient supplies and equipment, and their responsibilities may include
triaging patients and preparing patients for evacuation.
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treatment facility (typically a nonfederal hospital that has signed an
agreement with NDMS).
DHS has lead responsibility for the medical response function of NDMS.
DOD takes the lead in coordinating patient evacuation for NDMS, in
collaboration with DOT, the other NDMS federal partners, and commercial
transportation companies. VA and DOD share lead responsibility for
arranging definitive care, including tracking the availability of beds in
hospitals that participate in NDMS. 19
NDMS was used to supplement state and local patient evacuation efforts
during Hurricane Katrina and Hurricane Rita, which struck the Gulf Coast
several weeks after Hurricane Katrina. NDMS officials told us that
Hurricane Katrina was the first time that the patient evacuation and
definitive care components of NDMS were used for a large number of
patients. In response to state requests for assistance, NDMS moved people
from Louisiana after Hurricane Katrina and from Texas before Hurricane
Rita. In total, about 2,900 people were transported to NDMS patient
reception areas due to the two hurricanes.
Regulation of Hospitals CMS establishes federal regulations that hospitals and nursing homes must
and Nursing Homes meet to participate in the Medicare and Medicaid programs. 20 These
regulations relate to many aspects of hospital or nursing home operations,
such as health care services, dietetic services, and physical environment,
including emergency management. Hospitals that are accredited by
JCAHO or AOA are generally deemed to meet most of these Medicare and
Medicaid requirements; 21 no organizations have similar deeming authority
for nursing homes. 22 State agencies survey and certify nursing homes and
nonaccredited hospitals to ensure that they follow CMS requirements.
CMS provides guidance to state agencies in the CMS State Operations
Manual, which includes interpretive guidelines and survey procedures for
Participating hospitals regularly report the number of beds that they have available for
NDMS patients so that VA and DOD can quickly identify bed capacity when needed.
20 42 C.F.R. pts. 482 (for hospitals) and 483 (for nursing homes) (2005).
21 42 U.S.C. § 1395bb (2000).
22 In 2004, JCAHO accredited approximately 4,666 hospitals, which represented about
95 percent of all U.S. hospital beds. AOA accredits 165 hospitals.
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GAO-06-826 Evacuation of Hospitals and Nursing Homes
state agencies to assess compliance with CMS regulations. 23 In addition to
CMS requirements, JCAHO, AOA, and states can establish additional
requirements for hospitals and nursing homes.
Federal Reports on Health
Care Facility Evacuation
Due to Hurricane Katrina
A number of federal reports address the issue of evacuation and health
care facility disaster planning. These reports have in various ways called
for improvements in coordination. The White House report on lessons
learned from the federal response to Hurricane Katrina recommended that
agencies coordinate together to plan, train, and conduct exercises to
evacuate patients when state and local agencies are unable to do so in a
timely or effective manner. 24 The House of Representatives Select
Bipartisan Committee to Investigate the Preparation for and Response to
Hurricane Katrina reported that medical care and evacuations suffered
from a lack of advance preparations, inadequate communications, and
difficulties in coordinating efforts. 25 The select committee's report and a
DHS Office of Inspector General Performance Review of the Federal
Emergency Management Agency (FEMA) both noted that search and
rescue efforts during Hurricane Katrina were effective but could have
benefited from improved coordination among federal agencies. 26 The
Senate Committee on Homeland Security and Governmental Affairs
reported that federal agencies involved in providing medical assistance did
not have adequate resources or the right medical capabilities to fully meet
the medical needs arising from Katrina, such as meeting the needs of large
evacuee populations, and were forced to use improvised and unproven
techniques to meet those needs. 27 Further, the committee reported that the
federal government's medical response suffered from a lack of planning,
coordination, and cooperation.
The CMS State Operations Manual includes interpretive guidelines and survey procedures
for state agencies that assess compliance with CMS regulations.
24 Assistant to the President for Homeland Security and Counterterrorism, The Federal
Response to Hurricane Katrina: Lessons Learned (Feb. 23, 2006).
25 U.S. House of Representatives, February 2006.
26 Department of Homeland Security, Office of Inspector General, A Performance Review of
FEMA's Disaster Management Activities in Response to Hurricane Katrina, OIG-06-32
(Washington, D.C.: Mar. 31, 2006).
27 Committee on Homeland Security and Governmental Affairs, May 2006.
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GAO-06-826 Evacuation of Hospitals and Nursing Homes
Facility
Administrators Faced
Several Challenges
Related to
Evacuation, Including
Deciding Whether to
Evacuate, Securing
Transportation, and
Maintaining
Communication
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.
Facility Administrators
Faced Challenges in
Deciding Whether to
Evacuate or Shelter in
Place
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
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GAO-06-826 Evacuation of Hospitals and Nursing Homes
adequately care for patients and residents, including sufficient supplies,
food, water, and power. For example, a nursing home administrator in
Florida told us that the facility prepared for Hurricane Charley by
obtaining 10 days of food and water for its 120 residents plus additional
Meals, Ready-to-Eat 28 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
28 Meals, Ready-to-Eat are precooked meal kits developed for soldiers in combat conditions.
Page 12 GAO-06-826 Evacuation of Hospitals and Nursing Homes
after a hurricane because new supplies may not arrive for several days.
For example, a representative of a Florida nursing home association said
that facilities need at least 10 days of supplies to effectively shelter in
place until help can arrive. The need to be self-sufficient is especially
important when disasters affect entire communities and delay response
efforts, as demonstrated during hurricanes Charley and Katrina. Facilities
that were part of networks were able to call on their corporate offices or
sister facilities outside of the affected area to replenish needed supplies
after a hurricane. For example, one administrator said that the company
that owns his hospital has a division that tracks each facility's
preparedness resources, and the company's supply warehouse has
"disaster packs" of necessary supplies ready to be deployed in case of
emergency. Additionally, the company has large contracts in place so that
it can quickly obtain resources like fuel, generators, and staff.
Facility administrators noted that they were not always able to obtain
appropriate vehicles to accommodate their facilities' patient needs. While
some people can be moved using buses, some may require 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
Facility Administrators
Had Problems Related to
Transportation for Patient
Evacuations
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GAO-06-826 Evacuation of Hospitals and Nursing Homes
requirements, and others may have had vehicles that were badly damaged
by the hurricane. For example, one nursing home administrator said that
the bus company his facility contracted with required 24-hours notice
before a bus could be chartered, and that providing this notice was
difficult in a disaster situation. Some facilities relied upon local
government resources to provide assistance with evacuations, but when
an entire community was severely affected, local ambulances were
damaged or in short supply and therefore unavailable. For example, one
Florida hospital administrator had arranged for transportation through the
local emergency operations center (EOC), but the hurricane destroyed the
EOC. In contrast, when local officials in Mississippi faced a shortage of
ambulances immediately after Hurricane Katrina, they called upon a
national ambulance company, with which they had a contract, to provide
additional resources from Texas and Alabama. Officials noted that state
resources were not available after the storm and contracting with an
ambulance company with national resources was beneficial.
Facility Administrators
Faced Communication
Challenges Due to Damage
to Local Infrastructure
Caused by Hurricanes
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
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GAO-06-826 Evacuation of Hospitals and Nursing Homes
handheld radios and personal contact to communicate immediately after
the hurricane. We have previously reported on communication difficulties
during a public health emergency. 29
NDMS has two limitations in its design that constrain its assistance to
state and local governments with patient evacuation. First, NDMS is not
designed to move patients or residents out of hospitals or nursing homes
to mobilization centers. Second, NDMS was not designed nor is it
currently configured for people who do not need hospital care, including
nursing home residents.
The first limitation of NDMS is that it is designed to move patients from a
mobilization center, such as an airport, to other locations where they can
receive necessary medical care, but it is not designed to move patients or
residents out of hospitals or nursing homes to mobilization centers. NDMS
officials told us that transportation from a health care facility to an NDMS
mobilization center is the responsibility of local and state governments.
Moreover, NDMS does not include helicopters, ambulances, or other
short-distance vehicles necessary to move patients out of hospitals or
nursing homes to mobilization centers. NDMS officials stated that NDMS
transportation assets typically are large DOD airplanes designed to travel
long distances, which can take approximately 24 hours or more to arrange.
In addition, NDMS officials told us that to obtain ambulance or helicopter
service, they would contract with private providers near a disaster site,
which could lead to competition between the federal government and
state and local authorities for the same pool of limited resources. 30
Although NDMS evacuation efforts begin at mobilization centers, federal
officials told us that no federal program is designed to move patients or
residents out of hospitals or nursing homes to mobilization centers. NDMS
and other documents that we reviewed also do not identify other federal
programs that might assist in performing this function. We reviewed the
NRP, the September 2005 draft Catastrophic Incident Supplement to the
NRP, and NDMS documents. They do not indicate how the federal
See, for example, GAO, Bioterrorism: Information Technology Strategy Could
Strengthen Federal Agencies ' Abilities to Respond to Public Health Emergencies,
GAO-03-139 (Washington, D.C.: May 30, 2003).
30 For example, a DOT official told us that the federal government and the state of Texas
competed to obtain vehicles due to Hurricane Rita.
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
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GAO-06-826 Evacuation of Hospitals and Nursing Homes
government is to assist state and local authorities in moving hospital
patients and nursing home residents from their facilities. In particular, the
September 2005 draft Catastrophic Incident Supplement to the NRP,
which is intended to be used with the Catastrophic Incident Annex when a
catastrophic incident almost immediately overwhelms the capabilities of
state and local governments, states that collecting and transporting
patients from health care facilities to mobilization centers is the
responsibility of state and local authorities. The draft supplement does not
describe what, if any, role the federal government may play in
coordinating with state and local authorities for this kind of
transportation.
Despite this limitation of NDMS, some federal assistance was provided to
move people out of health care facilities during Hurricane Katrina. Coast
Guard officials told us that they evacuated about 9,400 people from
hospitals and nursing homes as part of their search and rescue operations.
NDMS officials reported that private, local, state, and federal resources
transported hospital patients and nursing home residents to mobilization
points, but there was a lack of coordination. For example, a report
prepared by NDMS officials after Hurricane Katrina noted that, initially,
transportation resources from the Coast Guard and DOD were not
coordinated. 31
The second limitation is that NDMS was not designed nor is it currently
configured for people who do not need hospital care, including nursing
home residents. As stated in the memorandum of agreement among the
NDMS federal partners, the patient evacuation function of NDMS is
intended to move patients so that they can receive medical care in NDMS
hospitals — typically nonfederal hospitals that have agreements with
NDMS. NDMS officials told us that they do not have agreements with
nursing homes or other types of health care providers. However, because
of the immediate demands posed by Hurricane Katrina, federal officials
told us that NDMS had to move people who did not need hospital care,
including nursing home residents and members of the general public who
arrived at NDMS mobilization centers. NDMS flights evacuated people
with various needs from mobilization centers to NDMS patient reception
areas where officials assessed their health needs and arranged for them to
NDMS, National Disaster Medical System (NDMS) After Action Review (AAR) Report
on Patient Movement and Definitive Care Operations in Support of Hurricanes Katrina
and Rita (Jan. 12, 2006).
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GAO-06-826 Evacuation of Hospitals and Nursing Homes
receive additional medical care through the definitive care portion of
NDMS. NDMS reception areas had to make special arrangements for
people in need of nursing home care, because NDMS lacked preexisting
agreements with nursing homes equipped to handle people with
nonhospital health care needs. 32 In a report prepared by NDMS after the
hurricane, federal officials noted that NDMS was not optimally prepared to
manage the nursing home requirements of evacuees who did not require
hospitalization. 33 The movement of nursing home residents during
evacuations is not addressed elsewhere in the NRP.
Federal Requirements
for Hospitals and
Nursing Homes
Include Provisions for
Having Disaster Plans
and Transferring
Patients Out of
Hospitals
At the federal level, CMS has requirements related to hospital and nursing
home disaster and evacuation planning as a condition of participation in
the Medicare and Medicaid programs. For hospitals, a CMS requirement
states that the overall hospital environment must be maintained to assure
the safety and well-being of patients. 34 According to CMS guidelines for
interpreting this regulation, hospitals must develop and maintain
comprehensive emergency plans, and when developing plans, should
consider the transfer of patients to other health care settings or hospitals if
necessary. For nursing homes, a CMS regulation states that facilities must
have plans to meet all potential emergencies and disasters, although the
interpretative guidelines do not specifically mention transfer of residents. 35
CMS officials told us that, based on experiences during Hurricane Katrina,
they have established a work group within CMS to review hospital and
nursing home requirements and other provider standards, policies, and
guidance related to emergency preparedness, including issues related to
evacuations. The officials told us that they expect the work group to make
initial recommendations for improvement in 2006. (See app. II for CMS
regulations and interpretive guidelines related to evacuation planning and
emergency preparedness.)
In addition to CMS requirements, JCAHO, AO A, 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
For related information, see GAO-06-443R.
'NDMS 2006.
l 42 C.F.R. § 482.41(a) (2005).
'42 C.F.R. § 483.75(m) (2005).
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GAO-06-826 Evacuation of Hospitals and Nursing Homes
patients, supplies, staff, and equipment to alternate care sites if
necessary. 36 AOA requires that emergency plans for hospitals that it
accredits include provisions for transferring patients and supplies to other
settings for health care if necessary. (See app. Ill for a list of JCAHO and
AOA requirements related to evacuation planning and emergency
preparedness.) States can also establish additional requirements for
facility evacuation planning that relate to transportation. For example,
Florida requires hospitals and nursing homes to have comprehensive
emergency management plans that document transportation arrangements
to be used to evacuate residents. 37 Mississippi requires nursing homes to
maintain written transfer agreements with other facilities or alternative
shelters in the event of a disaster. 38 The state also requires hospitals to
have written disaster preparedness plans that include relocation
arrangements, including transportation arrangements, in the event of an
evacuation. 39
Federal requirements for hospitals and nursing homes include provisions
that the facilities plan for disasters and emergencies. However, when
hurricanes Charley and Katrina hit the Gulf Coast area, they created
significant challenges for health care facility administrators that faced
evacuation, including deciding whether to evacuate, securing
transportation, and maintaining communications outside of their facilities.
In particular, securing transportation was challenging because when
multiple health care facilities within a community decided to evacuate,
they had difficulty obtaining the number and type of vehicles needed and
competed with each other for a limited supply of vehicles.
A federal role related to evacuation is described in various documents,
including the NDMS memorandum of agreement, the NRP, and its draft
Catastrophic Incident Supplement. However, the challenges faced by
hospitals and nursing homes during hurricanes Charley and Katrina also
36 However, JCAHO officials stated that, in a disaster that affects the entire community, the
requirements would not prevent multiple facilities from competing for the same
transportation resources or alternate care sites.
37 Fla. Stat. § 395.1055(l)(c) (2005); Fla. Admin. Code Ann. r. 59A-4.126 (2005); and
Emergency Mgmt. Planning Criteria for Nursing Home Facilities, ACHA 3110-6006, March
1994.
38 12-000-045 Miss. Code R. § 405.1 (Weil 2006).
39 12-000-040 Miss. Code R. § 1401.5 (Weil 2006).
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GAO-06-826 Evacuation of Hospitals and Nursing Homes
revealed two limitations in the federal government's support to health care
facilities that have to evacuate — the lack of assistance to states and
localities to move people out of health care facilities to a mobilization
point for federal transportation support and the lack of attention to
nursing home residents needing evacuation. In terms of the first limitation,
we found that the reliance in the NDMS design on local and state
resources to move people directly out of facilities is inadequate when
multiple facilities in the community have to evacuate simultaneously and
compete for too few vehicles. In addition, DHS's draft Catastrophic
Incident Supplement to the NRP, which is intended to offer guidance for a
situation in which state and local resources are overwhelmed, also would
leave responsibility for moving people out of health care facilities on state
and local authorities. It does not describe the role the federal government
may play in coordinating with state and local authorities during hospital
and nursing home evacuations. In terms of the second limitation, we noted
that the evacuation of nursing home residents was not considered when
NDMS was originally designed in 1984 — nor is it currently addressed
elsewhere in the NRP — but the experiences of these recent hurricanes also
showed that the needs of this population when evacuations are required
have been overlooked in the federal plans.
DHS is the lead agency responsible for issuance and maintenance of the
NRP, development of the draft Catastrophic Incident Supplement, and
activation of NDMS. Until it addresses these limitations — within NDMS,
the NRP, or through other mechanisms — vulnerabilities in the evacuation
of hospitals and nursing homes will continue, and the federal
government's response will not be as effective as possible.
R6COmm6ndcltiori.S for ^° ac ' c ' ress limitations in how the federal government provides assistance
with the evacuation of health care facilities, we recommend that the
Executive Action 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.
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GAO-06-826 Evacuation of Hospitals and Nursing Homes
Agency Comments
and Our Evaluation
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
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GAO-06-826 Evacuation of Hospitals and Nursing Homes
NRP to provide transportation support for domestic emergencies. Under
ESF #8, DOT can assist with identifying and arranging for all types of
transportation. However, as stated in the draft report, the NRP does not
indicate how DOT or other federal agencies are to assist state and local
authorities in moving hospital patients and nursing home residents from
their facilities. Second, HHS commented that the report does not describe
why NDMS was designed to focus on hospital evacuation, but HHS did not
provide any additional information about NDMS's origins. Although the
draft report included available information on the origins of NDMS, our
assessment focused on the program's current status. HHS's written
comments are reprinted in appendix VI.
VA agreed with our conclusions and recommendations and stated that it
would continue to address issues raised in the draft report. VA's written
comments are reprinted in appendix VII.
DHS and HHS also provided technical comments. In addition, DOT
provided technical comments via email. We incorporated these comments
where appropriate.
We are sending copies of this report to the Secretaries of DOD, HHS, DHS,
DOT, VA, and other interested parties. We will also make copies available
to others on request. In addition, the report will be available at no charge
on GAO's Web site at http://www.gao.gov.
If you or your staff have any questions about this report, please contact me
at (202) 512-7101 or bascettac@gao.gov. Contact points for our Offices of
Congressional Relations and Public Affairs may be found on the last page
of this report. GAO staff who made major contributions to this report are
listed in appendix VIII.
Cynthia A. Bascetta
Director, Health Care
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GAO-06-826 Evacuation of Hospitals and Nursing Homes
List of Committees
The Honorable Charles E. Grassley
Chairman
The Honorable Max Baucus
Ranking Minority Member
Committee on Finance
United States Senate
The Honorable Michael B. Enzi
Chairman
The Honorable Edward M. Kennedy
Ranking Minority Member
Committee on Health, Education,
Labor, and Pensions
United States Senate
The Honorable Susan M. Collins
Chairman
Committee on Homeland Security and
Governmental Affairs
United States Senate
The Honorable Daniel K. Akaka
Ranking Minority Member
Committee on Veterans' Affairs
United States Senate
The Honorable Gordon H. Smith
Chairman
The Honorable Herb Kohl
Ranking Minority Member
Special Committee on Aging
United States Senate
The Honorable Ike Skelton
Ranking Minority Member
Committee on Armed Services
House of Representatives
Page 22
GAO-06-826 Evacuation of Hospitals and Nursing Homes
The Honorable Joe Barton
Chairman
The Honorable John D. Dingell
Ranking Minority Member
Committee on Energy and Commerce
House of Representatives
The Honorable Tom Davis
Chairman
The Honorable Henry A. Waxman
Ranking Minority Member
Committee on Government Reform
House of Representatives
The Honorable Bennie G. Thompson
Ranking Minority Member
Committee on Homeland Security
House of Representatives
The Honorable Steve Buyer
Chairman
The Honorable Lane Evans
Ranking Minority Member
Committee on Veterans' Affairs
House of Representatives
The Honorable William M. Thomas
Chairman
The Honorable Charles B. Rangel
Ranking Minority Member
Committee on Ways and Means
House of Representatives
Page 23
GAO-06-826 Evacuation of Hospitals and Nursing Homes
Appendix I: Scope and Methodology
To examine the challenges hospital and nursing home administrators
faced related to recent hurricanes, we conducted case studies in two
states — Florida and Mississippi. We selected these states based on their
experience with previous disasters. During 2004, the state of Florida was
hit by four hurricanes — Charley, Frances, Ivan, and Jeanne. Hurricane
Charley was the strongest of these four, and the strongest hurricane to hit
the United States since Hurricane Andrew hit southern Florida in 1992. 1 In
2005, Mississippi received heavy storm damage from Hurricane Katrina
caused by wind and an extremely high storm surge.
In Florida, to understand the role of the state and local governments in
evacuating hospitals and nursing homes, we interviewed and obtained
documents from state and county officials. At the state level, we
interviewed officials from the Florida Department of Health's Office of
Emergency Operations. We reviewed the Florida Comprehensive
Emergency Management Plan, as well as Florida's after-action report for
the 2004 Hurricane season. At the local level, we selected two counties
affected by Hurricane Charley — Charlotte and Volusia counties. Charlotte
County, the entry point for the hurricane, is located on the Gulf Coast of
Florida. Volusia County, the exit point for the hurricane, is located on the
Atlantic Coast of the state. Within each county, we interviewed emergency
management officials and reviewed county emergency management plans.
To obtain information on the experiences of individual health care
facilities in Florida, we identified hospitals and nursing homes within each
of the selected counties, interviewed facility administrators, and reviewed
documents. To select facilities, we asked emergency management officials
in each county to provide contact information for hospitals and nursing
homes that either evacuated or sheltered in place due to Hurricane
Charley. In cases where the representatives identified by county officials
were unavailable, we selected alternate health care facilities based on
their proximity to the ocean. For each facility, we obtained and reviewed
applicable emergency plans, hurricane plans, and/or evacuation plans. In
total, we interviewed administrators from two hospitals and two nursing
homes in Charlotte County and one hospital and two nursing homes in
Volusia County. In addition to facility administrators, we interviewed
officials from the Florida Hospital Association, the Florida Association of
Homes for the Aging, and the Florida Health Care Association.
hurricane Charley was a category 4 storm on the Saffir-Simpson hurricane rating scale.
(Category 5 is the strongest possible category on the scale.)
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GAO-06-826 Evacuation of Hospitals and Nursing Homes
Appendix I: Scope and Methodology
In Mississippi, to understand the role of the state and local governments in
evacuating hospitals and nursing homes, we interviewed and obtained
documents from state and county officials. At the state level, we
interviewed officials from the Mississippi Emergency Management Agency
and Department of Health, and reviewed documents including the
Mississippi Comprehensive Emergency Management Plan. At the local
level, we selected the two coastal counties that were hit most directly by
Hurricane Katrina — Hancock and Harrison counties. Hancock County,
which includes the cities of Waveland and Bay St. Louis, was directly in
the path of the storm and sustained extensive damage. Harrison County,
which is adjacent to Hancock County and includes the cities of Gulfport
and Biloxi, sustained extensive damage and has the area's largest
population. In each county, we interviewed emergency management
officials. We also reviewed emergency management plans from Hancock
and Harrison counties.
To obtain information on the experience of individual health care facilities
in Mississippi, we identified hospitals, nursing homes, and assisted living
facilities within each of the selected counties; interviewed facility
administrators; and reviewed documents provided. To locate health care
facilities, we relied on a list of hospitals, nursing homes, and assisted living
facilities in Hancock and Harrison counties from a June 2005 Mississippi
Department of Health report on hospitals 2 and a September 2005
Mississippi Department of Health report on institutions for the aged or
infirm. 3 We also identified facilities in Harrison County that were operated
by the Department of Veterans Affairs (VA). We excluded nursing homes
with fewer than 20 licensed beds. From this list, we selected facilities
based on ownership type, vulnerability and proximity to the ocean, and
size. For each facility, we obtained and reviewed emergency plans,
hurricane plans, and/or evacuation plans. In total, we interviewed officials
from one hospital and one nursing home in Hancock County and four
hospitals and two assisted living facilities in Harrison County. We also
interviewed representatives from the Gulf States Association of Homes
and Services for the Aging.
Mississippi Department of Health, Division of Health Facilities Licensure and Certification,
2004 Report on Hospitals (Jackson, Miss.: June 2005).
Mississippi Department of Health, Bureau of Health Facilities Licensure and Certification,
2004 Report on Institutions for the Aged or Infirm (Jackson, Miss.: September 2005).
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GAO-06-826 Evacuation of Hospitals and Nursing Homes
Appendix I: Scope and Methodology
To examine the extent to which limitations exist in the design of the
National Disaster Medical System (NDMS) or other federal programs to
assist state and local governments with patient evacuations, we reviewed
federal documents such as the National Response Plan, including
Emergency Support Function #8 — Public Health and Medical Services —
and the Catastrophic Incident Annex. We also obtained and reviewed a
September 2005 draft of the Catastrophic Incident Supplement to the NRP.
We interviewed emergency preparedness officials from the Department of
Defense, the Department of Health and Human Services, the Department
of Homeland Security, the Department of Transportation, and the VA. To
obtain additional information on NDMS, we reviewed program documents,
including the memorandum of agreement that governs NDMS and an 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.
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Appendix II: CMS Regulations and
Interpretive Guidelines Related to Hospital
and Nursing Home Disaster and Evacuation
The Centers for Medicare & Medicaid Services (CMS) establishes federal
regulations that hospitals and nursing homes must meet to participate in
the Medicare and Medicaid programs. CMS's interpretive guidelines
contain authoritative interpretations and clarifications of statutory and
regulatory requirements and are to be used to make determinations about
compliance with requirements. The tables below include regulations for
hospitals and nursing homes that relate to disaster and evacuation
planning. Table 1 includes CMS regulations and interpretive guidelines for
hospitals.
Table 1: CMS Regulation and Interpretive Guidelines for Hospitals
Regulation 9
Interpretive guidelines
42 C.F.R. § 482.41(a)
Buildings
The condition of the physical plant and the
overall hospital environment must be
developed and maintained in such a manner
that the safety and well being of patients are
assured.
The hospital must ensure that the condition of the physical plant and overall hospital
environment is developed and maintained in a manner to ensure the safety and well
being of patients. This includes ensuring that routine and preventive maintenance and
testing activities are performed as necessary, in accordance with Federal and State
laws, regulations, and guidelines and manufacturer's recommendations, by establishing
maintenance schedules and conducting ongoing maintenance inspections to identify
areas or equipment in need of repair. The routine and preventive maintenance and
testing activities should be incorporated into the hospital's QAPI" plan.
Assuring the safety and well being of patients would include developing and
implementing appropriate emergency preparedness plans and capabilities. The hospital
must develop and implement a comprehensive plan to ensure that the safety and well
being of patients are assured during emergency situations. The hospital must
coordinate with Federal, State, and local emergency preparedness and health
authorities to identify likely risks for their area (e.g., natural disasters, bioterrorism
threats, disruption of utilities such as water, sewer, electrical communications, fuel;
nuclear accidents, industrial accidents, and other likely mass casualties, etc.) and to
develop responses that will assure the safety and well being of patients. The following
issues should be considered when developing the comprehensive emergency plan(s):
The differing needs of each location where the certified hospital operates;
The special needs of patient populations treated at the hospital (e.g., patients with
psychiatric diagnosis, patients on special diets, newborns, etc.);
Security of patients and walk-in patients;
Security of supplies from misappropriation;
Pharmaceuticals, food, other supplies and equipment that may be needed during
emergency/disaster situations;
Communication to external entities if telephones and computers are not operating or
become overloaded (e.g., ham radio operators, community officials, other healthcare
facilities if transfer of patients is necessary, etc.);
Communication among staff within the hospital itself;
Qualifications and training needed by personnel, including healthcare staff, security
staff, and maintenance staff, to implement and carry out emergency procedures;
Identification, availability and notification of personnel that are needed to implement
and carry out the hospital's emergency plans;
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Appendix II: CMS Regulations and
Interpretive Guidelines Related to Hospital
and Nursing Home Disaster and Evacuation
Regulation 9 Interpretive guidelines"
• Identification of community resources, including lines of communication and names
and contact information for community emergency preparedness coordinators and
responders;
• Provisions if gas, water, electricity supply is shut off to the community;
• Transfer or discharge of patients to home, other healthcare settings, or other
hospitals;
• Transfer of patients with hospital equipment to another hospital or healthcare setting;
and
• Methods to evaluate repairs needed and to secure various likely materials and
supplies to effectuate repairs.
Source: CMS State Operations Manual.
°GAO analyzed regulations and interpretive guidelines for hospitals that specifically pertain to
evacuation planning and emergency preparedness. For a full list of CMS regulations and interpretive
guidelines for hospitals, see the CMS State Operations Manual, Appendix A - Survey Protocol,
Regulations and Interpretive Guidelines for Hospitals.
"According to CMS, hospitals use a quality assessment performance improvement (QAPI) plan to
systematically examine quality and implement specific improvement projects on an ongoing basis.
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Appendix II: CMS Regulations and
Interpretive Guidelines Related to Hospital
and Nursing Home Disaster and Evacuation
Table 2 includes CMS regulations and interpretive guidelines for nursing
homes. CMS surveyors conduct health care facility surveys to evaluate the
manner and degree to which the providers satisfy various CMS
requirements or standards. Long-term care facilities include nursing
homes.
Table 2: CMS Guidance to Surveyors for Long Term Care Facilities
Regulation 9 Interpretive guidelines"
42 C.F.R. §483.70
Physical Environment
The facility must be designed, constructed,
equipped, and maintained to protect the health
and safety of residents, personnel and the public.
42 C.F.R. §483.75
Administration
A facility must be administered in a manner that
enables it to use its resources effectively and
efficiently to attain or maintain the highest
practicable physical, mental, and psychosocial
well-being of each resident.
42 C.F.R. §483.75(m)
Disaster and Emergency Preparedness
1 . The facility must have detailed written plans
and procedures to meet all potential
emergencies and disasters, such as fire,
severe weather, and missing residents.
2. The facility must train all employees in
emergency procedures when they begin to
work in the facility, periodically review the
procedures with existing staff, and carry out
unannounced staff drills using those
procedures.
Source: CMS State Operations Manual.
a GAO analyzed regulations and interpretive guidelines for nursing homes that specifically pertain to
evacuation planning and emergency preparedness. For a full list of CMS regulations and interpretive
guidelines for nursing homes, see the CMS State Operations Manual, Appendix PP - Guidance to
Surveyors for Long Term Care Facilities.
"Some regulations do not have interpretive guidelines.
The facility should tailor its disaster plan to its geographic location and the types
of residents it serves. "Periodic review" is a judgment made by the facility based
on its unique circumstances[.] [C]hanges in physical plan or changes external to
the facility can cause a review of the disaster review plan[.]
The purpose of a "staff drill" is to test the efficiency, knowledge, and response of
institutional personnel in the event of an emergency. Unannounced staff drills are
directed at the responsiveness of staff, and care should be taken not to disturb or
excite residents.
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Appendix III: JCAHO and AOA Requirements
for Hospital Evacuation Planning and
Emergency Preparedness
Hospitals that are accredited by the Joint Commission on Accreditation of
Healthcare Organizations (JCAHO) or the American Osteopathic
Association (AOA) are generally deemed to be compliant with the Centers
for Medicare & Medicaid Services requirements. The document and table
below include JCAHO and AOA requirements for hospitals that relate to
evacuation planning and emergency preparedness. The document includes
JCAHO hospital requirements, and table 3 includes AOA hospital
requirements.
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Appendix III: JCAHO and AOA Requirements
for Hospital Evacuation Planning and
Emergency Preparedness
Joint Commission on Accreditation of Healthcare Organizations
2006 Hospital Accreditation Standards for
Emergency Management Planning
Emergency Management Drills
Infection Control
Disaster Privileges
(Please note that standards addressing emergency management drills and disaster
privileges are undergoing additional research; revised standards for these areas are
forthcoming)
Standard EC.4.10
The hospital addresses emergency management.
Rationale for EC.4.10
An emergency 1 in the hospital or its community could suddenly and significantly affect
the need for the hospital's services or its ability to provide those services. Therefore, a
hospital needs to have an emergency management plan that comprehensively describes
its approach to emergencies in the hospital or in its community.
Elements of Performance for EC.4.10
1 . The hospital conducts a hazard vulnerability analysis 2 to identify potential emergencies
that could affect the need for its services or its ability to provide those services.
2. The hospital establishes the following with the community:
• Priorities among the potential emergencies identified in the hazard vulnerability
analysis
• The hospital's role in relation to a communitywide emergency management
program
• An "all-hazards" command structure within the hospital that links with the
community's command structure
3. The hospital develops and maintains a written emergency management plan describing
the process for disaster readiness and emergency management, and implements it when
'Emergency A natural or manmade event that significantly disrupts the environment of care (for example,
damage to the hospital's building(s) and grounds due to severe winds, storms, or earthquakes) that
significantly disrupts care, treatment and services (for example, loss of utilities such as power, water, or
telephones due to floods, civil disturbances, accidents, or emergencies within the hospital or in its
community); or that results in sudden, significantly changed, or increased demands for the hospital's
services (for example, bioterrorist attack, building collapse, plane crash in the organization's community).
Some emergencies are called "disasters" or "potential injury creating events" (PICEs).
2 Hazard vulnerability analysis: The identification of potential emergencies and the direct and indirect
effects these emergencies may have on the hospital's operations and the demand for its services.
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Appendix III: JCAHO and AOA Requirements
for Hospital Evacuation Planning and
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appropriate.
4. At a minimum, an emergency management plan is developed with the involvement of
the hospital's leaders including those of the medical staff .
5. The plan identifies specific procedures that describe mitigation, 3 preparedness, 4
response, and recovery strategies, actions, and responsibilities for each priority
emergency.
6. The plan provides processes for initiating the response and recovery phases of the plan,
including a description of how, when, and by whom the phases are to be activated.
7. The plan provides processes for notifying staff when emergency response measures are
initiated.
8. The plan provides processes for notifying external authorities of emergencies,
including possible community emergencies identified by the hospital (for example,
evidence of a possible bioterrorist attack).
9. The plan provides processes for identifying and assigning staff to cover all essential
staff functions under emergency conditions.
10. The plan provides processes for managing the following under emergency conditions:
• Activities related to care, treatment, and services (for example, scheduling,
modifying, or discontinuing services; controlling information about patients;
referrals; transporting patients)
• Staff support activities (for example, housing, transportation, incident stress
debriefing)
• Staff family support activities
• Logistics relating to critical supplies (for example, pharmaceuticals, supplies,
food, linen, water)
• Security (for example, access, crowd control, traffic control)
• Communication with the news media
1 1 . Not applicable
12. The plan provides processes for evacuating the entire building (both horizontally and,
when applicable, vertically) when the environment cannot support adequate care,
treatment, and services.
13. The plan provides processes for establishing an alternate care site(s) that has the
3 Mitigation activities Those activities a hospital undertakes in attempting to lessen the severity and impact
of a potential emergency.
4 Preparedness activities Those activities a hospital undertakes to build capacity and identify resources
that may be used if an emergency occurs.
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Appendix III: JCAHO and AOA Requirements
for Hospital Evacuation Planning and
Emergency Preparedness
capabilities to meet the needs of patients when the environment cannot support adequate
care, treatment, and services including processes for the following:
• Transporting patients, staff, and equipment to the alternative care site(s)
• Transferring to and from the alternative care site(s), the necessities of patients (for
example, medications, medical records)
• Tracking of patients
• Interfacility communication between the hospital and the alternative care site(s)
14. The plan provides processes for identifying care providers and other personnel during
emergencies.
15. The plan provides processes for cooperative planning with health care organizations
that together provide services to a contiguous geographic area (for example, among
organizations serving a town or borough) to facilitate the timely sharing of information
about the following:
• Essential elements of their command structures and control centers for
emergency response
• Names and roles of individuals in their command structures and command
center telephone numbers
• Resources and assets that could potentially be shared in an emergency response
• Names of patients and deceased individuals brought to their organizations to
facilitate identifying and locating victims of the emergency
16. Not applicable
1 7. Not applicable
18. The plan identifies backup internal and external communication systems in the event
of failure during emergencies.
1 9. The plan identifies alternate roles and responsibilities of staff during emergencies,
including to whom they report in the hospital's command structure and, when activated,
in the community's command structure.
20. The plan identifies an alternative means of meeting essential building utility needs
when the hospital is designated by its emergency management plan to provide continuous
service during an emergency (for example, electricity, water, ventilation, fuel sources,
medical gas/vacuum systems).
2 1 . The plan identifies means for radioactive, biological, and chemical isolation and
decontamination.
Standard EC.4.20
The hospital conducts drills regularly to test emergency management.
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Elements of Performance for EC.4.20
1 . The hospital tests the response phase of its emergency management plan twice a year,
either in response to an actual emergency or in planned drills. 5
Note: Staff in each freestanding building classified as a business occupancy (as defined
by the LSC) that does not offer emergency services nor is community-designated as a
disaster-receiving station need to participate in only one emergency management drill
annually. Staff in areas of the building that the hospital occupies must participate in this
drill.
Note: Tabletop exercises, though useful in planning or training, are only acceptable
substitutes for communitywide practice drills.
2. Drills are conducted at least four months apart and no more than eight months apart.
3. Hospitals that offer emergency services or are community-designated disaster
receiving stations must conduct at least one drill a year that includes an influx of
volunteers or simulated patients.
4. The hospital participates in at least one communitywide practice drill a year (where
applicable) relevant to the priority emergencies identified in its hazard vulnerability
analysis. The drill assesses the communication, coordination, and effectiveness of the
hospital's and community's command structures.
Note: "Communitywide " may range from a contiguous geographic area served by the
same health care providers, to a large borough, town, city, or region
Note: Tests of EPs 3 and 4 may be separate, simultaneous, or combined.
5. Not applicable
6. All drills are critiqued to identify deficiencies and opportunities for improvement.
Standard EC.7.20
The hospital provides an emergency electrical power source.
Rationale for EC.7.20
The hospital properly installs an emergency power source that is adequately sized,
designed, and fueled, as required by the LSC occupancy requirements and the services
provided.
Elements of Performance for EC.7.20
1 . The hospital provides a reliable emergency power system 6 , as required by the LSC
occupancy requirements, that supplies electricity to the following areas when normal
electricity is interrupted: Alarm systems
5 Drills that involve packages of information that simulate patients, their families, and the public are
acceptable.
6 Reliable emergency power system For guidance in establishing a reliable emergency power system (that
is, an Essential Electrical Distribution System), see NFPA 99-2002 edition (chapters 13 and 14).
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2. The hospital provides a reliable emergency power system, as required by the LSC
occupancy requirements, that supplies electricity to the following areas when normal
electricity is interrupted: Exit route illumination
3. The hospital provides a reliable emergency power system, as required by the LSC
occupancy requirements, that supplies electricity to the following areas when normal
electricity is interrupted: Emergency communication systems
4. The hospital provides a reliable emergency power system, as required by the LSC
occupancy requirements, that supplies electricity to the following areas when normal
electricity is interrupted: Illumination of exit signs
5. The hospital provides a reliable emergency power system, as required by the services
provided and patients served, that supplies electricity to the following areas when normal
electricity is interrupted: Blood, bone, and tissue storage units
6. Not applicable
7. The hospital provides a reliable emergency power system, as required by the services
provided and patients served, that supplies electricity to the following areas when normal
electricity is interrupted: Emergency/urgent care areas
8. The hospital provides a reliable emergency power system, as required by the services
provided and patients served, that supplies electricity to the following areas when normal
electricity is interrupted: Elevators (at least one for nonambulatory patients)
9. The hospital provides a reliable emergency power system, as required by the services
provided and patients served, that supplies electricity to the following areas when normal
electricity is interrupted: Medical air compressors
10. The hospital provides a reliable emergency power system, as required by the services
provided and patients served, that supplies electricity to the following areas when normal
electricity is interrupted: Medical and surgical vacuum systems
1 1 . The hospital provides a reliable emergency power system, as required by the services
provided and patients served, that supplies electricity to the following areas when normal
electricity is interrupted: Areas where electrically powered life-support equipment is used
12. Not applicable
13. Not applicable
14. The hospital provides a reliable emergency power system, as required by the services
provided and patients served, that supplies electricity to the following areas when normal
electricity is interrupted: Operating rooms
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for Hospital Evacuation Planning and
Emergency Preparedness
15. The hospital provides a reliable emergency power system, as required by the services
provided and patients served, that supplies electricity to the following areas when normal
electricity is interrupted: Postoperative recovery rooms
16. The hospital provides a reliable emergency power system, as required by the services
provided and patients served, that supplies electricity to the following areas when normal
electricity is interrupted: Obstetrical delivery rooms
1 7. The hospital provides a reliable emergency power system, as required by the services
provided and patients served, that supplies electricity to the following areas when normal
electricity is interrupted: Newborn nurseries
Standard EC.7.40
The hospital maintains, tests, and inspects its emergency power systems.
Rationale for EC.7.40
Note: This standard does not require hospitals to have the types of emergency power
systems discussed below. However, if a hospital has these types of systems, then the
following maintenance, testing, and inspection requirements apply.
Elements of Performance for EC.7.40
1 . The hospital tests each generator 1 2 times a year with testing intervals not less than 20
days and not more than 40 days apart. These tests shall be conducted for at least 30
continuous minutes under a dynamic load that is at least 30% of the nameplate rating of
the generator.
Note: Hospitals may choose to test to less than 30% of the emergency generator 's
nameplate. However, these hospitals shall (in addition to performing a test for 30
continuous minutes under operating temperature at the intervals described above) revise
their existing documented management plan to conform to current NFPA 99 and NFPA
110 testing and maintenance activities. These activities shall include inspection
procedures for assessing the prime movers ' exhaust gas temperature against the
minimum temperature recommended by the manufacturer.
If diesel-powered generators do not meet the minimum exhaust gas temperatures as
determined during these tests, they shall be exercised for 30 continuous minutes at the
intervals described above with available Emergency Power Supply Systems (SPSS) load,
and exercised annually with supplemental loads of
• 25% of name plate rating for 30 minutes, followed by
• 50% of name plate rating for 30 minutes, followed by
• 75% of name plate rating for 60 minutes for a total of two continuous hours.
2. The hospital tests all automatic transfer switches 12 times a year with testing intervals
not less than 20 days and not more than 40 days apart.
3. The hospital tests all battery-powered lights required for egress. Testing includes (a) a
functional test at 30-day intervals for a minimum of 30 seconds; and (b) an annual test for
a duration of 1 .5 hours.
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for Hospital Evacuation Planning and
Emergency Preparedness
4. The hospital tests Stored Emergency Power Supply Systems (SEPSS) whose
malfunction may severely jeopardize the occupants' life and safety. 7 Testing includes (a)
a quarterly functional test for 5 minutes or as specified for its class, 8 whichever is less;
and (b) an annual test at full load for 60% of the full duration of its class.
Standard IM.2.30
Continuity of information is maintained.
Rationale for IM.2.30
The purpose of the business continuity/disaster recovery plan is to identify the most
critical information needs for patient care, treatment, and services and business processes,
and the impact on the hospital if these information systems were severely interrupted.
The plan identifies alternative means for processing data, providing for recovery of data,
and returning to normal operations as soon as possible.
Elements of Performance for IM.2.30
1 . The hospital has a business continuity/disaster recovery plan for its information
systems.
2. For electronic systems, the business continuity/disaster recovery plan includes the
following:
• Plans for scheduled and unscheduled interruptions, which includes end-user
training with the downtime procedures
• Contingency plans for operational interruptions (hardware, software, or other
systems failure)
• Plans for minimal interruptions as a result of scheduled downtime
• An emergency service plan
• A back-up system (electronic or manual)
• Data retrieval, including retrieval from storage and information presently in the
operating system, retrieval of data in the event of system interruption, and back up
of data
3. The plan is tested periodically as defined by the hospital (or in accordance with law or
regulation) to ensure that the business interruption back-up techniques are effective.
7 Stored Emergency Power Supply Systems (SEPSS) Are intended to automatically supply illumination or power to
critical areas and equipment essential for safety to human life. Included are systems that supply emergency power for
such functions as illumination for safe exiting, ventilation where it is essential to maintain life, fire detection and alarm
systems, public safety communications systems, and processes where the current interruption would produce serious
life safety or health hazards to clients, the public, or staff. Note: Other non-SEPSS battery back-up emergency power
systems that an hospital has determined to be critical for operations during a power failure (for example, laboratory
equipment, electronic medical records) should be properly tested and maintained in accordance with manufacturer's
recommendations.
8 Class Defines the minimum time for which the SEPSS is designed to operate at its rated load without being recharged
(for additional guidance, see NFP A 111 (1 996 edition) Standard on Stored Electrical Energy Emergency and Standby
Power Systems).
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for Hospital Evacuation Planning and
Emergency Preparedness
4. The business continuity/disaster recovery plan is implemented when information
systems are interrupted.
Standard LD.3.1S
The leaders develop and implement plans to identify and mitigate impediments to
efficient patient flow throughout the hospital.
Rationale for LD.3.15
Managing the flow of patients through the organization is essential to the prevention and
mitigation of patient crowding, a problem that can lead to lapses in patient safety and
quality of care. The Emergency Department is particularly vulnerable to experiencing
negative effects of inefficiency in the management of this process. While Emergency
Departments have little control over the volume and type of patient arrivals and most
hospitals have lost the "surge capacity" that existed at one time to manage the elastic
nature of emergency admissions, other opportunities for improvement do exist.
Overcrowding has been shown to be primarily an organization-wide "system problem"
and not just a problem for which a solution resides within the emergency department.
Opportunities for improvement often exist outside the emergency department.
This standard emphasizes the role of assessment and planning for effective and efficient
patient flow throughout the organization. To understand the system implications of the
issues, leadership should identify all of the processes critical to patient flow through the
hospital system from the time the patient arrives, through admitting, patient assessment
and treatment, and discharge. Supporting processes such as diagnostic, communication,
and patient transportation are included if identified by leadership as impacting patient
flow. Relevant indicators are selected and data is collected and analyzed to enable
monitoring and improvement of processes.
A key component of the standard addresses the needs of admitted patients who are in
temporary bed locations awaiting an inpatient bed. Twelve key elements of care have
been identified to ensure adequate and appropriate care for admitted patients in temporary
locations. These elements have implications across the organization and should be
considered when planning care and services for these patients. Additional standard
chapters relevant to these key elements are shown in parenthesis.
• Life Safety Code issues (for example, patients in open areas) (EC)
• Patient privacy and confidentiality (RI)
• Cross training and coordination among programs and services to ensure adequate
staffing, particularly nursing staff (HR)
• Designation of a physician to manage the care of the admitted patient in a
temporary location, without compromising the quality of care given to other ED
patients (HR)
• Proper technology and equipment to meet patient needs (PC, LD)
• Appropriately privileged practitioners to provide patient care beyond immediate
emergency services (HR)
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Emergency Preparedness
• Access to other practitioners for consult and referral (for example, Intensivist)
(PC)
• Assurance of appropriate communication between all health care providers (LD)
• Access to ancillary services (for example, pharmacy, lab, dietary) which permit
the prompt disposition of patient care needs (LD)
• Patient access to medical assistance in an emergency, or for immediate care if
needed (for example, call bell) (PC)
• A comprehensive written care plan carried out in a timely fashion, inclusive of
intensive care issues (PC)
• Patient education on rights and access to services(PC)
Planning should also address the delivery of adequate care and services to those patients
for whom no decision to admit has been made, but who are placed in overflow locations
for observation or while awaiting completion of their evaluation.
Additionally, the standard calls for indicator results to be made available to those
individuals who are accountable for processes that support patient flow. These results
should be regularly reported to leadership to support their planning. The organization
should improve inefficient or unsafe processes identified by leadership as essential in the
efficient movement of patients through the organization. Criteria should be defined to
guide decisions about ambulance diversion.
Elements of Performance for LD.3.15
1 . Leaders assess patient flow issues within the hospital, the impact on patient safety, and
plan to mitigate that impact.
2. Planning encompasses the delivery of appropriate and adequate care to admitted
patients who must be held in temporary bed locations, for example, post anesthesia care
unit and emergency department areas.
3. Leaders and medical staff share accountability to develop processes that support
efficient patient flow.
4. Planning includes the delivery of adequate care, treatment, and services to non-
admitted patients who are placed in overflow locations.
5. Specific indicators are used to measure components of the patient flow process and
address the following:
• Available supply of patient bed space
• Efficiency of patient care, treatment, and service areas
• Safety of patient care, treatment and service areas
• Support service processes that impact patient flow
6. Indicator results are available to those individuals who are accountable for processes
that support patient flow.
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7. Indicator results are reported to leadership on a regular basis to support planning.
8. The hospital improves inefficient or unsafe processes identified by leadership as
essential to the efficient movement of patients through the organization.
9. Criteria are defined to guide decisions about initiating diversion.
Standard IC.6.10
As part of its emergency management activities, the hospital prepares to respond to an
influx, or the risk of an influx, of infectious patients.
Rationale for IC.6.10
The health care hospital is an important resource for the continued functioning of a
community. A hospital's ability to deliver care, treatment, or services is threatened when
it is ill-prepared to respond to an epidemic or infections likely to require expanded or
extended care capabilities over a prolonged period. Therefore, it is important for a
hospital to plan how to prevent the introduction of the infection into the hospital, how to
quickly recognize that existing patients have become infected, and/or how to contain the
risk or spread of the infection.
This planned response may include a broad range of options including the temporary
halting of services and/or admissions, delaying transfer or discharge, limiting visitors
within a hospital, or fully activating the hospital's emergency management plan. The
actual response depends upon issues such as the extent to which the community is
affected by the epidemic or infection, the types of services the hospital offers, and the
hospital's capabilities.
The concepts included in these standards are supported by standards found elsewhere in
the manual including standard EC. 4. 10.
Elements of Performance for IC.6.10
1 . The hospital determines its response to an influx or risk of an influx of infectious
patients.
2. The hospital has a plan for managing an ongoing influx of potentially infectious
patients over an extended period.
3. The hospital does the following:
• Determines how it will keep abreast of current information about the
emergence of epidemics or new infections which may result in the hospital
activating its response
• Determines how it will disseminate critical information to staff and other key
practitioners
• Identifies resources in the community (through local, state and/or federal
public health systems) for obtaining additional information
Source: JCAHO 2006 Hospital Accreditation Standards for Emergency Management Planning, Emergency Management Drills,
Infection Control, and Disaster Privileges © 2005 Used with permission.
Note: GAO obtained these standards from JCAHO in November 2005. According to JCAHO officials,
parts of the standards have since been revised.
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Table 3: 2005 AOA Accreditation Requirements for Hospitals
Standard
Description
1 1 .02.02 Building Safety .
The condition of the physical plant and the
overall hospital environment must be
developed and maintained in such a manner
that the safety and well being of patients,
visitors, and staff is assured.
The hospital must ensure that the condition of the physical plant and overall hospital
environment is developed and maintained in a manner to ensure the safety and well
being of patients. This includes ensuring that routine and preventive maintenance and
testing activities are performed as necessary, in accordance with Federal and State
laws, regulations, and guidelines and manufacturer's recommendations, by
establishing maintenance schedules and conducting ongoing maintenance inspections
to identify areas or equipment in need of repair. The routine and preventive
maintenance activities should be incorporated into the hospital's QAPI a plan.
The hospital must develop and implement a comprehensive plan to ensure that the
safety and well being of patients are assured during emergency situations. The
hospital must coordinate with Federal, State, and local emergency preparedness and
health authorities to identify likely risks for their area (e.g., natural disaster,
bioterrorism threats, disruption of utilities such as water, sewer, electrical
communications, fuel; nuclear accidents, industrial accidents, and other likely mass
casualties, etc.) and to develop appropriate responses that will assure that safety and
well being of patients.
The following issues should be considered when developing the comprehensive
emergency plans:
The differing needs of each location where the certified hospital operates
The special needs of patient populations treated at the hospital (e.g., patients
with psychiatric diagnosis)
Security of patients and walk-in patients
Security of supplies from misappropriation
Pharmaceuticals, food, other supplies and equipment that may be needed
during emergency/disaster situations
Communication to external entities if telephones and computers are not
operating emergency/disaster situations or become overloaded (e.g., ham
radio operators, community officials, other healthcare facilities if transfer of
patients is necessary, etc.)
Communication among staff within the hospital itself
Qualifications and training needed by personnel including healthcare staff,
security staff, and maintenance staff, to implement and carry out emergency
procedures
Identification, availability and notification of personnel that are needed to
implement and carry out the hospital's emergency plans
Identification of community resources, including lines of communication and
names and contact information for community emergency preparedness
coordinators and responders
Provisions if gas, water, electricity supply is shut off to the community
Transfer or discharge of patients to home, other healthcare settings, or other
hospitals
m. Transfer of patients with hospital equipment to another hospital or healthcare
setting; and
n. Methods to evaluate repairs needed and to secure various likely materials
and supplies to effectuate repairs
a.
b.
d.
e.
f.
I-
k.
I.
Page 41
GAO-06-826 Evacuation of Hospitals and Nursing Homes
Appendix III: JCAHO and AOA Requirements
for Hospital Evacuation Planning and
Emergency Preparedness
Standard
Description
1 1 .07.01 Disaster Plans .
Written disaster plans are developed,
maintained, and available to the staff for crisis
preparation
All disaster plans written by a hospital should be reviewed and coordinated with local
authorities so as to prevent confusion. Such authorities include, but are not limited to,
civil authorities (such as fire department, police department, public health department
or emergency medical service councils), and civil defense or military authorities. The
hospital shall provide an education program for staff and physicians for emergency
response preparedness. The hospital should also participate in community emergency
preparedness plans.
1 1 .07.02 External Disaster Plan-Victim
Triage .
The hospital's external disaster plan shall include the triaging of victims and includes
at least:
a. identification tags
b. placement of patients
c. notification of physicians; and
d. preliminary diagnosis of patients
The plan must address handling of communicable disease outbreaks and chemical
exposure victims.
1 1 .07.03 Disaster Drills.
Disaster drills are to be performed at least semiannually one of which shall include the
community.
1 1 .08.03 Maintenance Ensures Safety and
Quality .
Facilities, supplies, and equipment shall be
maintained to ensure an acceptable level of
safety and quality.
Facilities must be maintained to ensure an acceptable level of safety and quality.
Supplies must be maintained to ensure an acceptable level of safety and quality. This
would include that supplies are stored in such a manner to ensure the safety of the
stored supplies (protection against theft or damage, contamination, or deterioration),
as well as, that the storage practices do not violate fire codes or otherwise endanger
patients (storage of flammables, blocking passageways, storage of contaminated or
dangerous materials, safe storage practices for poisons, etc.)
Additionally, "supplies must be maintained to ensure an acceptable level of safety"
would include that the hospital identifies the supplies it needs to meet its patients'
needs for both day-to-day operations and those supplies that are likely to be needed in
likely emergency situations such as mass casualty events resulting from natural
disasters, mass trauma, disease outbreaks, etc.; and that the hospital makes
adequate provisions to ensure the availability of those supplies when needed.
Medical equipment and other equipment must be maintained in accordance with
manufacturers recommendations, laws, and NFPA" 99 chapters as appropriate.
Equipment includes both hospital equipment (e.g., elevators, generators, air handlers,
medical gas systems, air compressors and vacuum systems, etc.) and medical
equipment (e.g., biomedical equipment, radiological equipment, patient beds,
stretchers, IV infusion equipment, ventilators, laboratory equipment, etc.).
There must be a regular periodical maintenance and testing program for medical
devices and equipment. A qualified individual such as a clinical or biomedical
engineer, or other qualified maintenance person must monitor, test, calibrate and
maintain the equipment periodically in accordance with the manufacturer's
recommendations and federal and State laws and regulations. Equipment
maintenance may be conducted using hospital staff, contracts, or through a
combination of hospital staff and contracted services.
Page 42
GAO-06-826 Evacuation of Hospitals and Nursing Homes
Appendix III: JCAHO and AOA Requirements
for Hospital Evacuation Planning and
Emergency Preparedness
Standard Description
"Equipment must be maintained to ensure an acceptable level of safety" would include
that the hospital identifies the equipment it needs to meet its patients' needs for both
day-to-day operations and equipment that is likely to be needed in likely
emergency/disaster situations such as mass casualty events resulting from natural
disasters, mass trauma, disease outbreaks, internal disasters, etc.; and that the
hospital makes adequate provisions to ensure the availability of that equipment when
needed.
Source: Accreditation Requirements for Healthcare Facilities © 2005, Healthcare Facilities Accreditation Program (HFAP) of the
American Osteopathic Association. Used with permission.
"Quality assessment performance improvement.
"National Fire Protection Association.
Page 43
GAO-06-826 Evacuation of Hospitals and Nursing Homes
Appendix IV: Comments from the
Department of Homeland Security
U.S. Department ui" Humeland Security
Washington, DC 20528
Homeland
'W* Security
July 7, 2006
Ms. Cynthia A. Bascetta
Director, Health Care
U.S. Government Accountability Office
441 G Street, NW
Washington, DC 20548
Dear Ms. Bascetta:
RE: Draft Report GAO-06-826, Disaster Preparedness: Limitations in Federal
Evacuation Assistance for Health Facilities Should be Addressed
(GAO Job Code 290503)
The Department of Homeland Security appreciates the opportunity to review and
comment on the draft report. The Government Accountability Office (GAO)
recommends that the Secretary of Homeland Security (1) 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
National Disaster Medical System (NDMS) transportation begins; and (2) in consultation
with 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.
We will take the recommendations under advisement as we review the National Response
Plan. However, the primary responsibility for evacuations, including evacuations from
hospitals and nursing homes, remains with state and local governments. The Federal
government becomes involved only when the capabilities of the state and local
governments are overwhelmed. Moreover, as GAO states, the National Disaster Medical
System is limited in its design and operational capabilities with respect to evacuating
patients from hospitals and nursing homes. These limitations are defined by a
Memorandum of Agreement (MOA) among the NDMS Federal partners (National
Disaster Medical System Federal Partners MOA, October 25, 2005).
Pursuant to Federal Emergency Management Agency after-action analyses of activities
during Hurricane Katrina and the findings of this audit, all of the NDMS Federal partners
are currently reviewing the MOA with a view towards working with our state and local
partners to alter, delineate, and otherwise clarify roles and responsibilities as appropriate.
www.dhs.gov
Page 44
GAO-06-826 Evacuation of Hospitals and Nursing Homes
Appendix IV: Comments from the Department
of Homeland Security
2
These efforts will create better understanding and communication of the roies defined in
the MOA, and the appropriate separation of Federal versus state and local roles.
Sincerely,
Steven J . Pecinovsky
Director
Departmental GAO/OIG Liaison Office
Page 45
GAO-06-826 Evacuation of Hospitals and Nursing Homes
Appendix V: Comments from the Department
of Defense
THE ASSISTANT SECRETARY OF DEFENSE
WASHINGTON, D. C. 20301-1200
HEALTH AFFAIRS
Ms. Cynthia A. Bascetta
Director, Health Care
U.S. Government Accountability Office
441 G. Street, N.W.
Washington, DC 20548
Dear Ms. Bascetta:
This is the Department of Defense (DoD) response to the Government
Accountability Office (GAO) Draft Report entitled, "DISASTER PREPAREDNESS:
Limitations in Federal Evacuation Assistance for Health Facilities Should Be
Addressed," dated June 14, 2006, GAO Code 290503/GAO-06-826.
Thank you for the opportunity to review and comment on the draft report. I
appreciate the collaborative, insightful, and thorough approach your team has taken with
this important issue. A basic conclusion of your report is that the National Disaster
Medical System (NDMS) has two limitations that "constrain" its assistance to state and
local governments with patient evacuation. The first 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. The second limitation is that the
NDMS was not designed, nor is it currently configured, to move nursing home residents.
We disagree with both of these conclusions. By describing NDMS as being
"constrained" by these two limitations, you arc essentially saying that the provision of
such disaster response assets (short transportation) is a federal responsibility. It is not.
You might better describe the limitations and/or deficiencies as those of state and local
government. The federal government's role should not be to provide local ambulance
service, or even local helicopter lift (a responsibility that could be ably filled by state
national guard). Your second conclusion regarding the lack of configurement of NDMS
to deal with nursing home patients, though technically correct, did not prove to be a
problem in the case of Hurricane Rita, which you fail to describe. In that situation, over
3,000 chronically ill patients, many from nursing homes, were moved within 24 hours
notice out of harm's way from Port Arthur, Texas to various locations in the region,
entirely through the NDMS and the efforts of TRANSCOM. It was a spectacular
success, and unfortunately you did not mention it.
We look forward to the final report and hope that it takes proper note of the
respective roles and responsibilities that should be assumed by the federal government,
Page 46
GAO-06-826 Evacuation of Hospitals and Nursing Homes
Appendix V: Comments from the Department
of Defense
versus state and local governments, and even private institutions that have serious and
chronically ill patients under their care.
My points-of-contact for additional information are Lieutenant Colonel William
Joseph Kormos (functional) at (703) 614-4157 and Mr. Gunther Zimmerman (Audit
Liaison) at (703) 681-3492, extension 4065.
Sincerely,
William
Page 47
GAO-06-826 Evacuation of Hospitals and Nursing Homes
Appendix VI: Comments from the
Department of Health and Human Services
DEPARTMENT OF HEALTH & HUMAN SERVICES
Washington, D.C. 20201
Office of Inspector General
Ms. Cynthia A. Bascetta JUt - 1 c < uuo
Director, Health Care
U.S. Government Accountability Office
Washington, DC 20548
Dear Ms. Bascetta:
The Department of Health and Human Services (HHS) appreciates the opportunity to review
and comment on the U.S. Government Accountability Office's (GAO) draft report entitled,
"DISASTER PREPAREDNESS: Limitations in Federal Evacuation Assistance for Health
Facilities Should be Addressed" (GAO-06-826), before its publication.
The report focuses on the role of the National Disaster Medical System (NDMS) and the
NDMS Federal partners. Given the focus of the report on Federal evacuation assistance, GAO
should also address the role the Department of Transportation has in the National Response
Plan to provide transportation support for domestic emergencies (e.g. contracting for
ambulances).
This document says many times that NDMS lacked or did not have preexisting agreements with
nursing homes, or that NDMS is not designed to move patients or residents out of their facilities
but doesn't adequately describe why. It would help if the reader were given more information
explaining the reasons that the system was designed to only focus on hospital evacuation.
The Department provided several technical comments directly to your staff.
These comments and the concurrence of the recommendation represent the tentative position of
the Department and are subject to reevaluation when the final version of the report is received.
The Office of Inspector General (OIG) is transmitting the Department's response to this draft
report in our capacity as the Department's designated focal point and coordinator for U.S.
Government Accountability Office reports. OIG has not conducted an independent
assessment of these comments and therefore expresses no opinion on them.
Sincerely,
Daniel R. Levinson
Inspector General
Enclosure
Page 48
GAO-06-826 Evacuation of Hospitals and Nursing Homes
Appendix VII: Comments from the
Department of Veterans Affairs
THE DEPUTY SECRETARY OF VETERANS AFFAIRS
WASHINGTON
July 5, 2006
Ms. Cynthia A. Bascetta
Director
Health Care Team
U. S. Government Accountability Office
441 G Street, NW
Washington, DC 20548
Dear Ms. Bascetta:
The Department of Veterans Affairs (VA) has reviewed the Government
Accountability Office's (GAO) draft report, DISASTER PREPAREDNESS:
Limitations in Federal Evacuation Assistance for Health Facilities Should
be Addressed (GAO-06-826) and agrees with your conclusions and
recommendations. As a member of the National Disaster Medical System
(NDMS), VA will continue to participate actively to address issues you have
raised in your report, particularly regarding improved responsiveness to nursing
home patients needing to be evacuated. VA will also continue to coordinate
closely with other NDMS Federal partners to assure that identified limitations are
addressed appropriately.
VA appreciates the opportunity to comment on your draft report.
Sincerely yours,
Gordon H. Mansfield
Page 49
GAO-06-826 Evacuation of Hospitals and Nursing Homes
Appendix VIII: GAO Contact and Staff
Acknowledgments
Contact Cynthia A. Bascetta at (202) 512-7101 or bascettac@gao.gov
Acknowledgments * n Edition *° * ne con tact named above, key contributors to this report
" were Linda T. Kohn, Assistant Director; La Sherri Bush; Krister Friday;
Nkeruka Okonmah; and William Simerl.
Page 50 GAO-06-826 Evacuation of Hospitals and Nursing Homes
Related GAO Products
Disaster Preparedness: Preliminary Observations on the Evacuation of
Vulnerable Populations due to Hurricanes and Other Disasters. GAO-06-
790T. Washington, D.C.: May 18, 2006.
Hurricane Katrina: Status of the Health Care System in New Orleans
and Difficult Decisions Related to Efforts to Rebuild It Approximately 6
Months After Hurricane Katrina. GAO-06-576R. Washington, D.C.:
March 28,2006.
Hurricane Katrina: GAO's Preliminary Observations Regarding
Preparedness, Response, and Recovery. GAO-06-442T. Washington, D.C.:
March 8, 2006.
Disaster Preparedness: Preliminary Observations on the Evacuation of
Hospitals and Nursing Homes Due to Hurricanes. GAO-06-
443R. Washington, D.C.: February 16, 2006.
HHS Bioterrorism Preparedness Programs: States Reported Progress but
Fell Short of Program Goals for 2002. GAO-04-360R. Washington, D.C.:
February 10, 2004.
Bioterrorism: Public Health Response to Anthrax Incidents of 2001.
GAO-04-152. Washington, D.C.: October 15, 2003.
Hospital Preparedness: Most Urban Hospitals Have Emergency Plans
but Lack Certain Capacities for Bioterrorism Response. GAO-03-924.
Washington, D.C.: August 6, 2003.
Bioterrorism: Information Technology Strategy Could Strengthen
Federal Agencies' Abilities to Respond to Public Health Emergencies.
GAO-03-139. Washington, D.C.: May 30, 2003.
Bioterrorism: Preparedness Varied across State and Local Jurisdictions.
GAO-03-373. Washington, D.C.: April 7, 2003.
(290503)
Page 51
GAO-06-826 Evacuation of Hospitals and Nursing Homes
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