Disaster Preparedness
Limitations in Federal Evacuation Assistance for Health Facilities Should be Addressed Gao ID: GAO-06-826 July 20, 2006Hurricane Katrina demonstrated difficulties involved in evacuating communities and raised questions about how hospitals and nursing homes plan for evacuations and how the federal government assists. Due to broad-based congressional interest, GAO assessed the evacuation of hospital patients and nursing home residents. Under the Comptroller General's authority to conduct evaluations on his own initiative, GAO examined (1) the challenges hospital and nursing home administrators faced, (2) the extent to which limitations exist in the design of the National Disaster Medical System (NDMS) to assist with patient evacuations, and (3) the federal requirements for hospital and nursing home disaster and evacuation planning. GAO reviewed documents and interviewed federal officials, and interviewed hospital and nursing home administrators and state and local officials in areas affected by Hurricane Katrina in Mississippi and Hurricane Charley in Florida.
Hospital and nursing home administrators faced several challenges related to evacuations during recent hurricanes, including deciding whether to evacuate or stay in their facilities and "shelter in place", obtaining transportation necessary for evacuations, and maintaining communication outside of their facilities. Administrators took steps to ensure that their facilities had needed resources--including staff, supplies, food, water, and power--to provide care during the hurricane and maintain self-sufficiency immediately after. However, when evacuations were needed, facility administrators said that they had problems with transportation, such as securing the vehicles needed to evacuate patients. Although facility administrators had contracts with transportation companies, competition for the same pool of vehicles created supply shortages when multiple facilities in a community had to be evacuated. In addition, communication was impaired by hurricane damage. For example, a nursing home in Florida was unable to communicate with local emergency managers. NDMS is a partnership of four federal agencies, and has two limitations in its design that constrain its assistance to state and local governments with patient evacuation. The NDMS partners are the Department of Defense, the Department of Health and Human Services (HHS), the Department of Homeland Security (DHS), and the Department of Veterans Affairs; DHS is the lead agency. The first limitation is that NDMS evacuation efforts begin at a mobilization center, such as an airport, and do not include short-distance transportation assets, such as ambulances or helicopters, to move patients out of health care facilities to mobilization centers. The second limitation is that NDMS supports the evacuation of patients needing hospital care; the program was not designed nor is it currently configured to move people who do not require hospitalization, such as nursing home residents. Although NDMS moved nursing home residents due to Hurricane Katrina who were brought to mobilization centers, NDMS officials had to make special arrangements for people in need of nursing home care because NDMS lacked preexisting agreements with nursing homes. Neither of these limitations is addressed in other documents GAO reviewed, including DHS's National Response Plan (NRP). At the federal level, HHS's Centers for Medicare & Medicaid Services (CMS) has requirements related to hospital and nursing home evacuation planning as a condition of participation in the Medicare and Medicaid programs. CMS requires that hospitals maintain the overall hospital environment to assure patient safety, including developing plans that consider the transfer of patients to other health care settings. For nursing homes, CMS requires that plans meet all potential emergencies and disasters; however, requirements do not specifically mention the transfer of residents. In addition to assessing compliance with CMS requirements, the Joint Commission on Accreditation of Healthcare Organizations, the American Osteopathic Association, and states can also have additional emergency management requirements.
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Director: Team: Phone:GAO-06-826, Disaster Preparedness: Limitations in Federal Evacuation Assistance for Health Facilities Should be Addressed
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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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