Limitations in Federal Evacuation Assistance for Health Facilities Should be Addressed
GAO-06-826: Published: Jul 20, 2006. Publicly Released: Jul 20, 2006.
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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.
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.
Recommendations for Executive Action
Status: Closed - Implemented
Comments: The primary responsibility for the National Disaster Medical System, and correspondingly for this recommendation, was transferred to HHS in 2007. HHS has implemented this recommendation by completing the following four actions. (1) HHS and DHS collaborated with state and local departments of health in hurricane-prone regions to determine gaps between needs and available resources for hospital and nursing home evacuations and to determine local, state, or federal resources to fill the gaps. (2) Based on this analysis, HHS and DHS contracted for ground and air ambulances and para-transit services for Gulf and East Coast states. (3) HHS encouraged states to establish regional coalitions for mutual aid. (4) HHS has completed a hurricane "playbook" that improves the clarity of the role of federal assistance in evacuations. GAO reported on this implementation in April 2008 in GAO-08-544R.
Recommendation: To address limitations in how the federal government provides assistance with the evacuation of health care facilities, the Secretary of Homeland Security should 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.
Agency Affected: Department of Homeland Security
Status: Closed - Implemented
Comments: The primary responsibility for the National Disaster Medical System (NDMS), and correspondingly for this recommendation, was transferred to HHS in 2007. HHS has substantially implemented this recommendation. In GAO-08-544R (April 2008), we reported that HHS and DHS collaborated with state and local departments of health in hurricane-prone regions to determine gaps between needs and available resources for hospital and nursing home evacuations and to determine local, state, or federal resources to fill the gaps. Nursing homes were included in this analysis. Based on this analysis, HHS and DHS contracted for ground and air ambulances and para-transit services for Gulf and East Coast states. These vehicles could be used to evacuate nursing home residents. Although we noted in the April 2008 report that the federal role in the evacuation of nursing home residents was not specifically addressed in the hurricane "playbook" that described the role of federal assistance in evacuations, HHS has since modified the playbook to include consideration of nursing home needs during evacuations as an area that should be considered when planning the response to an incident. In addition, in the report we noted that HHS had not provided evidence that it had clarified the role of NDMS in evacuating nursing home residents, but HHS has since stated clearly that the NDMS memorandum of agreement provides for federal assistance in relocating these residents. In addition, the Catastrophic Incident and Mass Evacuation Incident Annexes to the National Response Framework now include information on meeting the needs of nursing home residents. Finally, HHS formed an Interagency Patient Movement Working Group to describe the process of moving a medical evacuee, including nursing home residents, from their point of origin to a destination at a safe facility. This group has drafted a Movement of Patient Evacuees document that covers nursing home residents. This document describes how state officials must determine patient movement requirements and request federal support, including what information the states must supply to the federal government and what support they can expect to receive. As of August 21, 2009, this document was still in draft form, and was being formally staffed for review and comment to federal departments and state authorities.
Recommendation: To address limitations in how the federal government provides assistance with the evacuation of health care facilities, the Secretary of Homeland Security should, 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.
Agency Affected: Department of Homeland Security