Disaster Response: HHS Should Address Deficiencies Highlighted by Recent Hurricanes in the U.S. Virgin Islands and Puerto Rico

GAO-19-592 Published: Sep 20, 2019. Publicly Released: Sep 20, 2019.
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Fast Facts

The catastrophic destruction caused by Hurricanes Irma and Maria overwhelmed the U.S. Virgin Islands and Puerto Rican governments and resulted in a large federal disaster response.

The Department of Health and Human Services led federal public health and medical services efforts. Among other things, it provided medical personnel and facilities and evacuated critical care and dialysis patients.

We identified shortcomings in HHS’s efforts, such as insufficient staffing at emergency operations centers that contributed to confusion over the status of evacuated patients. We made 7 recommendations, including that HHS ensure adequate staffing.

HHS’s Disaster Medical Assistance Team Setting Up a Temporary Medical Clinic in Puerto Rico, October 2017

A team of people organizing boxes of supplies

A team of people organizing boxes of supplies

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Highlights

What GAO Found

The catastrophic destruction encountered as a result of Hurricanes Irma and Maria proved overwhelming to the U.S. Virgin Islands and Puerto Rican governments and resulted in a large federal disaster response, complicated by losses of power, communication, and health care infrastructure. The Department of Health and Human Services (HHS) led the federal public health and medical services response and undertook numerous actions to address the needs in the territories—including evacuating critical care and dialysis patients from the U.S. Virgin Islands and Puerto Rico and providing medical personnel and facilities.

However, GAO identified several shortcomings in HHS's leadership. While the scale, location, and timing of these storms complicated response efforts, the deficiencies GAO identified were in many cases a function of preparedness policies, or lack thereof. As a result, they could adversely affect future large-scale responses unless addressed. For example, as the lead agency, HHS is responsible for ensuring that appropriate planning activities are undertaken, including monitoring the federal ability to provide core public health and medical services response capabilities. However, GAO found that

HHS did not have a full understanding of the capabilities and limitations of its support agencies, including the Departments of Defense, Homeland Security, and Veterans Affairs. Consequently, HHS's needs were not always aligned with the resources that its support agencies could provide, resulting in some deployed resources not being properly and efficiently utilized. For example, HHS requested Department of Defense medical teams, but these teams specialized in trauma and surgical care, not the chronic and primary care needed.

HHS lacked plans for the territories that accounted for the chronic and primary care needs in isolated communities. This care was greatly needed, given that many, especially the elderly, could not easily access hospitals.

Example of Downed Power Lines in Puerto Rico, November 2017

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Why GAO Did This Study

Hurricanes Irma and Maria hit the U.S. Virgin Islands and Puerto Rico within two weeks of each other in September 2017, causing catastrophic damage. HHS is responsible for leading the federal public health and medical services response during a disaster, such as these hurricanes. As part of its lead federal role during these hurricanes, HHS called upon support agencies, including the Departments of Defense, Homeland Security, and Veterans Affairs, to assist with the public health and medical services response.

GAO was asked to review the federal public health and medical services response to Hurricanes Irma and Maria in the U.S. Virgin Islands and Puerto Rico. This report examines HHS's actions and leadership of this response, among other things. GAO reviewed documentation on the preparedness for, and response to, the hurricanes. It also interviewed federal and territory officials and interviewed or received written responses from eight nonfederal stakeholders involved in the response, such as nongovernmental organizations. GAO identified these stakeholders through research and referrals.

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Recommendations

GAO is making seven recommendations, including that HHS develop agreements with support agencies that include response capability and limitation information, and develop response plans for providing care in isolated communities. HHS disagreed with two of the seven citing, among other things, territory responsibility for plans. GAO clarified the intent of the two recommendations and believes that all seven are warranted.

Recommendations for Executive Action

Agency Affected Recommendation Status
Office of the Assistant Secretary for Preparedness and Response
Priority Rec.
This is a priority recommendation.
ASPR should develop a response personnel strategy to ensure, at a minimum, a lead ASPR liaison officer is consistently at the local emergency operations center(s) during an emergency support functions (ESF) #8 response and another liaison, if not more, is at strategic location(s) in the area. (Recommendation 1)
Closed – Implemented
ASPR agreed with this recommendation. ASPR officials told us in May 2019, and reiterated in March 2021, February 2022, and January 2023 that their incident response framework includes a long-term goal of creating an incident response team that will establish an initial ESF#8 presence at local emergency operations centers and manage resources and capabilities. If implemented, this strategy may allow ASPR to provide more liaisons on the ground during a response and address the staffing deficiency we identified. As of January 2023, ASPR has added 100 intermittent federal employee positions to aid in future response operations and support coordination at the local and regional level. According to ASPR, these positions were added within each of the 10 HHS regions. The first round of hiring notices resulted in 46 selections of qualified applicants. The second round resulted in 44 selections and personnel started in positions in September 2021. As of January 2023, ASPR officials stated that one primary responsibility of these personnel is supporting emergency operations centers as and when needed, and that they have few vacancies. This fulfills the intent of the recommendation.
Office of the Assistant Secretary for Preparedness and Response As ASPR finalizes its federal patient movement framework, the agency should exercise the framework with its National Disaster Medical System (NDMS) partners to ensure that patients evacuated through NDMS will be consistently tracked from the start of their evacuation. (Recommendation 2)
Open
The U.S. Department of Health and Human Services (HHS) concurred with the recommendation GAO made in September 2019. As of January 2023, HHS stated that the federal patient movement framework was exercised via a real-world event in 2020 in support of COVID-19 response operations originating in Asia. HHS's Air Medical Evacuation teams, which are part of the National Disaster Medical System (NDMS), directly supported 39 flights, moving over 2,000 individuals who tested positive for COVID-19, individuals under observation, or individuals who were asymptomatic. According to HHS officials, all movement was tracked via HHS' Joint Patient Assessment and Tracking System. HHS also stated it exercised the federal patient movement framework with NDMS partners during scheduled exercises, including Ultimate Caduceus 2022, and Patriot North. As of January 2023, ASPR officials explained that these exercises were done jointly with the Department of Defense (DoD), with DoD as the lead. GAO will keep this recommendation open until it can review relevant after action reports to understand the extent the framework was tested to ensure consistent tracking of evacuated patients.
Office of the Assistant Secretary for Preparedness and Response ASPR should put controls in place to ensure data on all NDMS evacuated patients are complete and accurate. (Recommendation 3)
Open
HHS officials concurred with this recommendation. In February 2022, ASPR officials stated that they hired a nurse consultant into NDMS who is the lead for the case management program. As of January 2023, according to officials, NDMS is in the process of exploring opportunities to develop case management teams. It also implemented a contract solution for case management and receives case management support from the Public Health Service. In addition, officials stated that the contract including the Joint Patient Assessment and Tracking System (JPATS), would be opened for competition in 2022 (anticipated June 2022). Officials stated the new contract would incorporate recommendations from federal partners at the Departments of Defense, State, and Veterans Affairs and would address this recommendation. However, as of January 2023, ASPR officials stated that the recompete on the NDMS contract managing JPATS is currently on a stop work order. Enhancements have not yet been made to the system and no new work can be completed on JPATS until the re-compete is complete.
Office of the Assistant Secretary for Preparedness and Response ASPR Region II should revise its Incident Response Plans for the territories to include strategies for providing chronic and primary care in isolated communities. These strategies could include the incorporation of Federally Qualified Health Centers and other local health clinics as part of a response. (Recommendation 4)
Closed – Implemented
HHS stated in 2019 and reiterated in March 2021 that it does not concur with this recommendation. In its comments on the draft report, HHS stated that while ASPR has federal plans in place that guide federal response, each state and locality is responsible for developing its own individual plans. As of January 2023, ASPR officials explained that they have held meetings with the Puerto Rico Governor's office, Puerto Rico Dept. of Health, Public Health emergency preparedness, the VA, FEMA, and PREMB. On December 7, 2022, ASPR officials also provided documentation of the coordination of a "hub and spoke model," developed during Hurricane Maria and finalized during the recovery phase. This "hub and spoke model" defines how each medical center could move patients and resources during a disaster. It identifies "Hub" facilities that have capacity to absorb surge from the "spoke" hospitals, including remote facilities. ASPR officials provided documentation that this model was discussed with multiple regional officials between February 2021 and February 2022. During this timeframe, ASPR officials also assisted regions with identifying areas needing collaboration, putting mutual aid agreements in place, and holding technical assistance meetings and exercises to identify implementation challenges and ensure lines of communication were open. This fulfills the intent of the recommendation.
Office of the Assistant Secretary for Preparedness and Response
Priority Rec.
This is a priority recommendation.
ASPR should work with support agencies to develop and finalize memorandums of agreement that include information on the capabilities and limitations of these agencies to meet ESF#8 core capabilities. (Recommendation 5)
Open
In its comments on the draft report and subsequently in May 2021 and January 2023, the U.S. Department of Health and Human Services (HHS) stated it did not concur with this September 2019 recommendation. In its most recent comments, HHS responded that the National Response Framework articulates how ESFs operate during incident response, and that further agreements are not needed to outline functions and responsibilities. In addition, HHS stated it does not plan to develop a list of capabilities because capabilities can change, and due to the structure of the National Response Framework, all agency partners can quickly come together during a response to collaborate and coordinate resources. GAO agrees that HHS and all partners may be able to come together quickly to collaborate and coordinate resources during a response. However, as is evidenced by the capabilities misalignment identified in our report, this was not adequate during the response to Hurricanes Irma and Maria in the U.S. Virgin Islands and Puerto Rico. Further, as GAO reported, ASPR officials acknowledged that more needs to be done to better understand the resources available from its support agencies. GAO maintains that it is essential for ASPR to take steps to ensure it has a sufficient understanding of each ESF#8 support agency's potential capabilities and limitations. Taking such action is needed to help ensure that future emergency responses are more efficiently and effectively coordinated.
Office of the Assistant Secretary for Preparedness and Response ASPR should develop a strategy demonstrating how it ESF#8 core capabilities can be provided through HHS and ESF#8 support agencies if DOD's capacity to respond is limited. (Recommendation 6)
Open
The U.S. Department of Health and Human Services (HHS) concurred with this September 2019 recommendation. In May 2021 and subsequently in January 2022 and January 2023, HHS officials stated that the Assistant Secretary for Preparedness and Response (ASPR) has implemented some changes to its response procedures since the issuance of GAO's report. For example, HHS officials stated that ASPR developed an Incident Response Framework that articulates how ASPR engages with its ESF#8 partners, including the establishment of an action officer-level group chaired by ASPR. HHS officials stated that this group reviews immediate, unmet operational needs, identifies appropriate sources of federal support, develops resource allocation course of action recommendations, and supports actions by the Secretary of HHS's Operations Center. In addition, HHS stated that ASPR established an executive level oversight group that serves as a forum for ASPR to engage with senior representatives of supporting agencies to find solutions to problems and elicit support for courses of action. According to ASPR, these meetings are meant to occur as needed during emergency responses. While GAO agrees these are important steps to ensure communication between partners during a response, the intent of GAO's recommendation was for ASPR to develop a strategy for ensuring ESF#8 core capabilities can be provided without the assistance of the Department of Defense prior to responding to an emergency rather than concurrent with a response.
Office of the Assistant Secretary for Preparedness and Response ASPR should take steps to ensure the perspectives of key external parties are incorporated in the development of HHS's after-action reviews, following future ESF#8 activations. (Recommendation 7)
Open
The U.S. Department of Health and Human Services (HHS) concurred with the recommendation GAO made in September 2019. As of January 2023, HHS officials stated that, since GAO's last update, the Assistant Secretary for Preparedness and Response's (ASPR's) Exercise Evaluation and After Action Team has a standing corrective action collaboration with the Centers for Disease Control and Prevention as well as the Federal Emergency Management Agency's Continuous Improvement Program to share data and observations for collaborative events and responses. HHS officials stated that, as conditions warrant, the Exercise Evaluation and After Action Team expands these collaborations for ongoing data sharing with the interagency collaboration. This is a positive step in response to the recommendation. GAO will review documentation of this interagency data sharing and collaboration when provided by HHS, in part, to determine with which parties ASPR's Exercise Evaluation and After Action Team has expanded collaboration beyond the Centers for Disease Control and Prevention and the Federal Emergency Management Agency's Continuous Improvement Program. GAO reviewed the Standard Operating Procedures for the Exercise Evaluation and After Action Team but did not find specific information to support that ASPR has taken steps to ensure the perspectives of key external parties are incorporated in the development of HHS's after-action reviews. Without an after-action report that includes the perspectives of all key parties--including ESF#8 support agencies--ASPR management is likely to lack the necessary information to comprehensively identify all strengths and areas for improvement of its ESF#8 response.

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