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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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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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GAO-06-826 Evacuation of Hospitals and Nursing Homes 



treatment facility (typically a nonfederal hospital that has signed an 
agreement with NDMS). 

DHS has lead responsibility for the medical response function of NDMS. 
DOD takes the lead in coordinating patient evacuation for NDMS, in 
collaboration with DOT, the other NDMS federal partners, and commercial 
transportation companies. VA and DOD share lead responsibility for 
arranging definitive care, including tracking the availability of beds in 
hospitals that participate in NDMS. 19 

NDMS was used to supplement state and local patient evacuation efforts 
during Hurricane Katrina and Hurricane Rita, which struck the Gulf Coast 
several weeks after Hurricane Katrina. NDMS officials told us that 
Hurricane Katrina was the first time that the patient evacuation and 
definitive care components of NDMS were used for a large number of 
patients. In response to state requests for assistance, NDMS moved people 
from Louisiana after Hurricane Katrina and from Texas before Hurricane 
Rita. In total, about 2,900 people were transported to NDMS patient 
reception areas due to the two hurricanes. 



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). 



Page 17 



GAO-06-826 Evacuation of Hospitals and Nursing Homes 



patients, supplies, staff, and equipment to alternate care sites if 
necessary. 36 AOA requires that emergency plans for hospitals that it 
accredits include provisions for transferring patients and supplies to other 
settings for health care if necessary. (See app. 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). 



Page 18 



GAO-06-826 Evacuation of Hospitals and Nursing Homes 



revealed two limitations in the federal government's support to health care 
facilities that have to evacuate — the lack of assistance to states and 
localities to move people out of health care facilities to a mobilization 
point for federal transportation support and the lack of attention to 
nursing home residents needing evacuation. In terms of the first limitation, 
we found that the reliance in the NDMS design on local and state 
resources to move people directly out of facilities is inadequate when 
multiple facilities in the community have to evacuate simultaneously and 
compete for too few vehicles. In addition, DHS's draft Catastrophic 
Incident Supplement to the NRP, which is intended to offer guidance for a 
situation in which state and local resources are overwhelmed, also would 
leave responsibility for moving people out of health care facilities on state 
and local authorities. It does not describe the role the federal government 
may play in coordinating with state and local authorities during hospital 
and nursing home evacuations. In terms of the second limitation, we noted 
that the evacuation of nursing home residents was not considered when 
NDMS was originally designed in 1984 — nor is it currently addressed 
elsewhere in the NRP — but the experiences of these recent hurricanes also 
showed that the needs of this population when evacuations are required 
have been overlooked in the federal plans. 

DHS is the lead agency responsible for issuance and maintenance of the 
NRP, development of the draft Catastrophic Incident Supplement, and 
activation of NDMS. Until it addresses these limitations — within NDMS, 
the NRP, or through other mechanisms — vulnerabilities in the evacuation 
of hospitals and nursing homes will continue, and the federal 
government's response will not be as effective as possible. 



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. 



Page 19 



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 



Page 21 



GAO-06-826 Evacuation of Hospitals and Nursing Homes 



List of Committees 

The Honorable Charles E. Grassley 
Chairman 

The Honorable Max Baucus 
Ranking Minority Member 
Committee on Finance 
United States Senate 

The Honorable Michael B. Enzi 
Chairman 

The Honorable Edward M. Kennedy 
Ranking Minority Member 
Committee on Health, Education, 
Labor, and Pensions 
United States Senate 

The Honorable Susan M. Collins 
Chairman 

Committee on Homeland Security and 
Governmental Affairs 
United States Senate 

The Honorable Daniel K. Akaka 
Ranking Minority Member 
Committee on Veterans' Affairs 
United States Senate 

The Honorable Gordon H. Smith 
Chairman 

The Honorable Herb Kohl 
Ranking Minority Member 
Special Committee on Aging 
United States Senate 

The Honorable Ike Skelton 
Ranking Minority Member 
Committee on Armed Services 
House of Representatives 



Page 22 



GAO-06-826 Evacuation of Hospitals and Nursing Homes 



The Honorable Joe Barton 
Chairman 

The Honorable John D. Dingell 
Ranking Minority Member 
Committee on Energy and Commerce 
House of Representatives 

The Honorable Tom Davis 
Chairman 

The Honorable Henry A. Waxman 
Ranking Minority Member 
Committee on Government Reform 
House of Representatives 

The Honorable Bennie G. Thompson 
Ranking Minority Member 
Committee on Homeland Security 
House of Representatives 

The Honorable Steve Buyer 
Chairman 

The Honorable Lane Evans 
Ranking Minority Member 
Committee on Veterans' Affairs 
House of Representatives 

The Honorable William M. Thomas 
Chairman 

The Honorable Charles B. Rangel 
Ranking Minority Member 
Committee on Ways and Means 
House of Representatives 



Page 23 



GAO-06-826 Evacuation of Hospitals and Nursing Homes 



Appendix I: Scope and Methodology 



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.) 



Page 24 



GAO-06-826 Evacuation of Hospitals and Nursing Homes 



Appendix I: Scope and Methodology 



In Mississippi, to understand the role of the state and local governments in 
evacuating hospitals and nursing homes, we interviewed and obtained 
documents from state and county officials. At the state level, we 
interviewed officials from the Mississippi Emergency Management Agency 
and Department of Health, and reviewed documents including the 
Mississippi Comprehensive Emergency Management Plan. At the local 
level, we selected the two coastal counties that were hit most directly by 
Hurricane Katrina — Hancock and Harrison counties. Hancock County, 
which includes the cities of Waveland and Bay St. Louis, was directly in 
the path of the storm and sustained extensive damage. Harrison County, 
which is adjacent to Hancock County and includes the cities of Gulfport 
and Biloxi, sustained extensive damage and has the area's largest 
population. In each county, we interviewed emergency management 
officials. We also reviewed emergency management plans from Hancock 
and Harrison counties. 

To obtain information on the experience of individual health care facilities 
in Mississippi, we identified hospitals, nursing homes, and assisted living 
facilities within each of the selected counties; interviewed facility 
administrators; and reviewed documents provided. To locate health care 
facilities, we relied on a list of hospitals, nursing homes, and assisted living 
facilities in Hancock and Harrison counties from a June 2005 Mississippi 
Department of Health report on 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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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 
Emergency Preparedness 



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



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



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



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. 



Page 40 



GAO-06-826 Evacuation of Hospitals and Nursing Homes 



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



Table 3: 2005 AOA Accreditation Requirements for Hospitals 



Standard 



Description 



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. 



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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) 



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GAO-06-826 Evacuation of Hospitals and Nursing Homes 



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