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entitled 'Disaster Preparedness: Limitations in Federal Evacuation 
Assistance for Health Facilities Should be Addressed' which was 
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Report to Congressional Committees: 

United States Government Accountability Office: 

GAO: 

July 2006: 

Disaster Preparedness: 

Limitations in Federal Evacuation Assistance for Health Facilities 
Should be Addressed: 

Evacuation of Hospitals and Nursing Homes: 

GAO-06-826: 

GAO Highlights: 

Highlights of GAO-06-826, a report to congressional committees 

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 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. 

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. 

[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-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. 

[End of Section] 

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: 

Appendix I: Scope and Methodology: 

Appendix II: CMS Regulations and Interpretive Guidelines Related to 
Hospital and Nursing Home Disaster and Evacuation: 

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

Appendix IV: Comments from the Department of Homeland Security: 

Appendix V: Comments from the Department of Defense: 

Appendix VI: Comments from the Department of Health and Human Services: 

Appendix VII: Comments from the Department of Veterans Affairs: 

Appendix VIII: GAO Contact and Staff Acknowledgments: 

Related GAO Products: 

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: 

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: 

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.[Footnote 
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.[Footnote 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)[Footnote 3] provides a framework for how the federal government 
is to assist states and localities in managing domestic incidents, 
including both incidents of national significance and those of lesser 
severity.[Footnote 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.[Footnote 5] NDMS 
is a partnership of four federal agencies, and the Department of 
Homeland Security (DHS) is the lead agency.[Footnote 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).[Footnote 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.[Footnote 8] In February 
2006, we reported on preliminary observations from our work,[Footnote 
9] and in May 2006, we testified on our preliminary observations before 
the Senate Special Committee on Aging.[Footnote 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.[Footnote 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, 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. 

Results 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 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 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. 

Background: 

At the federal level, the NRP provides a framework for how the federal 
government is to assist states and localities in managing emergencies 
and major disasters. NDMS is one of the programs identified in the NRP 
that can supplement state and local medical resources during 
emergencies, including providing resources to assist with evacuation. 
At the individual facility level, hospitals and nursing homes must 
comply with CMS requirements to participate in the Medicare and 
Medicaid programs. Several recently issued federal reports have looked 
at the adequacy of health care facility disaster planning, as prompted 
by Hurricane Katrina. 

The National Response Plan: 

In December 2004, DHS issued the NRP to consolidate existing federal 
government emergency response plans into a single coordinated plan, as 
mandated by the Homeland Security Act of 2002.[Footnote 12] The NRP 
provides a framework for how the federal government is to assist states 
and localities in managing domestic incidents, including an 
"emergency"[Footnote 13] or a "major disaster"[Footnote 14] declared by 
the President under the Robert T. Stafford Disaster Relief and 
Emergency Assistance Act (Stafford Act).[Footnote 15] On May 25, 2006, 
DHS revised the NRP to address certain weaknesses or ambiguities 
identified following Hurricane Katrina.[Footnote 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.[Footnote 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 
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 Medical System: 

NDMS, one of the programs included in ESF #8--Public Health and Medical 
Services--of the NRP, was formed in 1984 to care for massive numbers of 
casualties generated in a domestic disaster or an overseas conventional 
war. It is a nationwide medical response system to supplement state and 
local medical resources during disasters and emergencies and to provide 
back-up medical support to the military and VA health care systems 
during an overseas conventional conflict. DOD, HHS, DHS, and VA are 
federal partners in NDMS. These partners most recently signed a 
memorandum of agreement in October 2005 that describes the roles and 
responsibilities of each partner. DHS has the authority to activate 
NDMS in response to public health emergencies, which include, but are 
not limited to, presidentially declared emergencies or major disasters 
under the Stafford Act. 

NDMS consists of three key functions: 

* medical response, which includes medical equipment and supplies, 
patient triage, and other emergency health care services provided to 
disaster victims at a disaster site through NDMS medical response teams 
such as Disaster Medical Assistance Teams (DMAT);[Footnote 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 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.[Footnote 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 and Nursing Homes: 

CMS establishes federal regulations that hospitals and nursing homes 
must meet to participate in the Medicare and Medicaid 
programs.[Footnote 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;[Footnote 21] no organizations have similar deeming 
authority for nursing homes.[Footnote 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 state agencies to assess compliance with CMS 
regulations.[Footnote 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.[Footnote 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.[Footnote 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.[Footnote 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.[Footnote 27] Further, the committee 
reported that the federal government's medical response suffered from a 
lack of planning, coordination, and cooperation. 

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 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[Footnote 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 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 Had Problems Related to Transportation for 
Patient Evacuations: 

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 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 
handheld radios and personal contact to communicate immediately after 
the hurricane. We have previously reported on communication 
difficulties during a public health emergency.[Footnote 29] 

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: 

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.[Footnote 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 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.[Footnote 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 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.[Footnote 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.[Footnote 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.[Footnote 
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.[Footnote 
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, AOA, 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 patients, supplies, staff, and equipment to alternate 
care sites if necessary.[Footnote 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. III 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.[Footnote 37] Mississippi requires nursing homes to maintain 
written transfer agreements with other facilities or alternative 
shelters in the event of a disaster.[Footnote 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.[Footnote 39] 

Conclusions: 

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 
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. 

Recommendations for Executive Action: 

To address limitations in how the federal government provides 
assistance with the evacuation of health care facilities, we recommend 
that the 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. 

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 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 [Hyperlink, 
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. 

Signed by: 

Cynthia A. Bascetta: 
Director, Health Care: 

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: 

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

[End of section] 

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.[Footnote 40] 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. 

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[Footnote 41] and a September 2005 Mississippi Department of 
Health report on institutions for the aged or infirm.[Footnote 42] 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. 

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. 

[End of section] 

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[A]: 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; 
Interpretive guidelines[B]: 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[B] 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. 
* 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. 

[A] 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. 

[B] 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. 

[End of table]

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[A]: 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; Interpretive 
guidelines[B]; 
Interpretive guidelines[B]: [Empty]. 

Regulation[A]: 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; 
Interpretive guidelines[B]: [Empty]. 

Regulation[A]: 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; 
Interpretive guidelines[B]: 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. Changes 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. 

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. 

[B] Some regulations do not have interpretive guidelines. 

[End of table] 

[End of section] 

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. 

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[Footnote 43] 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[Footnote 44]  
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 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[Footnote 45], preparedness[Footnote 46]," 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: 

11. 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 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: 

17. Not applicable: 

18. The plan identifies backup internal and external communication 
systems in the event of failure during emergencies. 

19. 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). 

21. 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. 

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[Footnote 47].  
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[Footnote 
48], as required by the LSC occupancy requirements, that supplies 
electricity to the following areas when normal electricity is 
interrupted: Alarm systems: 

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: 

11. 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: 

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: 

17. 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 12 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 (EPSS) 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. 

4. The hospital tests Stored Emergency Power Supply Systems (SEPSS) 
whose malfunction may severely jeopardize the occupants' life and 
safety[Footnote 49]. Testing includes (a) a quarterly functional test 
for 5 minutes or as specified for its class[Footnote 50], 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. 

4. The business continuity/disaster recovery plan is implemented when 
information systems are interrupted. 

Standard LD.3.15: 

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): 

* 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. 

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: 

Standard MS.4.110: 

Disaster privileges may be granted when the emergency management plan 
has been activated and the organization is unable to handle the 
immediate patient needs (see standard EC.4.10). 

Rationale for MS.4.110: 

During disaster(s) in which the emergency management plan has been 
activated, the CEO or medical staff president or their designee(s) has 
the option to grant disaster privileges. 

Elements of Performance for MS.4.110: 

A 1. The medical staff identifies in writing the individual(s) 
responsible for granting disaster privileges. 

A 2. The medical staff describes in writing the responsibilities of the 
individual(s) granting disaster privileges. (The responsible individual 
is not required to grant privileges to any individual and is expected 
to make such decisions on a case-by-case basis at his or her 
discretion.) 

B 3. The medical staff describes in writing a mechanism to manage 
individuals who receive disaster privileges. 

A 4. The medical staff includes a mechanism to allow staff to readily 
identify these individuals. 

A 5. The medical staff addresses the verification process as a high 
priority. 

A 6. The medical staff begins the verification process of the 
credentials and privileges of individuals who receive disaster 
privileges as soon the immediate situation is under control. 

A 7. This verification process is identical to the process established 
under the medical staff bylaws or other documents for granting 
temporary privileges to meet an important patient care need (see 
standard MSA.100). 

B 8. The CEO or president of the medical staff or their designec(s) may 
grant disaster privileges upon presentation of any of the following: 

* A current picture hospital ID card: 

* A current license to practice and a valid picture ID issued by a 
state, federal, or regulatory agency: 

* Identification indicating that the individual is a member of a 
Disaster Medical Assistance Team (DMAT): 

* Identification indicating that the individual has been granted 
authority to render patient care, treatment, and services in disaster 
circumstances (such authority having been granted by a federal, state, 
or municipal entity): 

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. 

Table 3: 2005 AOA Accreditation Requirements for Hospitals: 

Standard: 11.02.02 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; 
Description: 
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:. 

a. The differing needs of each location where the certified hospital 
operates. 

b. The special needs of patient populations treated at the hospital 
(e.g., patients with psychiatric diagnosis). 

c. Security of patients and walk-in patients. 

d. Security of supplies from misappropriation. 

e. Pharmaceuticals, food, other supplies and equipment that may be 
needed during emergency/disaster situations. 

f. 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.) 

g. Communication among staff within the hospital itself. 

h. Qualifications and training needed by personnel including healthcare 
staff, security staff, and maintenance staff, to implement and carry 
out emergency procedures. 

i. Identification, availability and notification of personnel that are 
needed to implement and carry out the hospital's emergency plans. 

j. Identification of community resources, including lines of 
communication and names and contact information for community emergency 
preparedness coordinators and responders. 

k. Provisions if gas, water, electricity supply is shut off to the 
community. 

l. 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. 

Standard: 11.07.01 Disaster Plans: Written disaster plans are 
developed, maintained, and available to the staff for crisis 
preparation; 
Description: 
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. 

Standard: 11.07.02 External Disaster Plan-Victim Triage; 
Description: 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. 

Standard: 11.07.03 Disaster Drills; 
Description: Disaster drills are to be performed at least semiannually 
one of which shall include the community. 

Standard: 11.08.03 Maintenance Ensures Safety and Quality: Facilities, 
supplies, and equipment shall be maintained to ensure an acceptable 
level of safety and quality; 
Description: 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[B] 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. 

"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. 

[A] Quality assessment performance improvement. 

[B] National Fire Protection Association. 

[End of table] 

[End of section] 

Appendix IV: Comments from the Department of Homeland Security: 

U.S. Department or Homeland Security: 
Washington, DC 20528: 

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. These efforts will create better understanding and 
communication of the roles defined in the MOA, and the appropriate 
separation of Federal versus state and local roles. 

Sincerely, 

Signed by:  

Steven J. Pecinovsky: 
Director: 
Departmental GAO/OIG Liaison Office: 

[End of section] 

Appendix V: Comments from the Department of Defense: 

The Assistant Secretary Of Defense: 
Washington, D. C. 20301-1200: 

Health Affairs: 

Ms. Cynthia A. Baseetta: 
Director, Health Care: 
U.S. Government Accountability Office: 
441 G. Street, N.W. 
Washington, DC 20548: 

Jul 6 2006: 

Dear Ms. Baseetta: 

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 are 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, 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, 

Signed by: 

William Winkenwerder, Jr., MD: 

[End of section] 

Appendix VI: Comments from the Department of Health and Human Services:

Department Of Health & Human Services: 
Office Of Inspector General: 
Washington, D.C. 20201: 

Ms. Cynthia A. Bascetta: 
Director, Health Care: 
U.S. Government Accountability Office: 
Washington, DC 20548: 

Jul 12 2005: 

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. 

Sincerely, 

Signed by:  

Daniel R. Levinson Inspector General: 

Enclosure: 

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. 

[End of section] 

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. 

Signed by: 

Gordon H. Mansfield: 

[End of section] 

Appendix VIII: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Cynthia A. Bascetta at (202) 512-7101 or bascettac@gao.gov: 

Acknowledgments: 

In addition to the contact named above, key contributors to this report 
were Linda T. Kohn, Assistant Director; La Sherri Bush; Krister Friday; 
Nkeruka Okonmah; and William Simerl. 

[End of section] 

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): 

FOOTNOTES 

[1] For 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. 

[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-11). 

[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. 

[7] 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). 

[9] 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). 

[11] 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. 

[12] Pub. 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). 

[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. 

[18] 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. 

[19] 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. 

[23] 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. 

[28] Meals, Ready-to-Eat are precooked meal kits developed for soldiers 
in combat conditions. 

[29] 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. 

[31] 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). 

[32] For related information, see GAO-06-443R. 

[33] NDMS 2006. 

[34] 42 C.F.R. § 482.41(a) (2005). 

[35] 42 C.F.R. § 483.75(m) (2005). 

[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(1)(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). 

[40] Hurricane Charley was a category 4 storm on the Saffir-Simpson 
hurricane rating scale. (Category 5 is the strongest possible category 
on the scale.) 

[41] Mississippi Department of Health, Division of Health Facilities 
Licensure and Certification, 2004 Report on Hospitals (Jackson, Miss.: 
June 2005). 

[42] Mississippi Department of Health, Bureau of Health Facilities 
Licensure and Certification, 2004 Report on Institutions for the Aged 
or Infirm (Jackson, Miss.: September 2005). 

[43] 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). 

[44] 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. 

[45] Mitigation activities Those activities a hospital undertakes in 
attempting to lessen the severity and impact of a potential emergency. 

[46] Preparedness activities Those activities a hospital undertakes to 
build capacity and identify resources that may be used if an emergency 
occurs. 

[47] Drills that involve packages of information that simulate 
patients, their families, and the public are acceptable. 

[48] 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). 

[49] 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. 

[50] Class Defines the minimum time for which the SEPSS is designed to 
operate at its rated load without being recharged (for additional 
guidance, see NFPA 1 11 (1996 edition) Standard on Stored Electrical 
Energy Emergency and Standby Power Systems). 

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