Status of Implementation of GAO Recommendations on Evacuation of Transportation-Disadvantaged Populations and Patients and Residents of Health Care Facilities
Gao ID: GAO-08-544R April 1, 2008Many of the approximately 100,000 people who did not evacuate before Hurricane Katrina struck the Gulf Coast in 2005 lacked access to a vehicle. In the aftermath of the storm, questions were raised about how well federal, state, and local governments were prepared to evacuate such transportation-disadvantaged populations. Hurricane Katrina, which ultimately resulted in over 1,300 deaths, also demonstrated difficulties for evacuating hospital patients and nursing home residents and raised questions about the role of the federal government in assisting in such evacuations. While responding to disasters and managing evacuations is largely a state and local responsibility, the federal government can provide assistance when state and local governments are overwhelmed. The federal government also provides grants and technical assistance for disaster preparedness. In January 2008, the Department of Homeland Security (DHS) released the National Response Framework (NRF)--replacing the National Response Plan. Its annexes detail the roles and responsibilities of local, state, and federal agencies during emergencies. The Federal Emergency Management Agency (FEMA), within DHS, is the lead coordinating agency for federal emergency assistance. The NRF details the responsibilities of supporting federal agencies, including the Department of Transportation (DOT), whose responsibilities include coordinating the restoration and recovery of transportation systems and infrastructure, and the Department of Health and Human Services (HHS), whose responsibilities include coordinating public health and medical services. The federal government can provide medical resources, such as emergency medical care and the evacuation of hospital patients during disasters, through the National Disaster Medical System (NDMS), a partnership of DHS, the Department of Defense, the Department of Veterans Affairs, and HHS. Recently, Congress expressed concerns about the extent to which GAO's recommendations have been implemented and asked us to assess the progress these agencies have made in doing so.
GAO found that progress implementing our recommendations has been mixed. Of the six recommendations contained in the two reports, two recommendations have been substantially implemented, while three recommendations have been partially implemented, and one recommendation has not been implemented.
GAO-08-544R, Status of Implementation of GAO Recommendations on Evacuation of Transportation-Disadvantaged Populations and Patients and Residents of Health Care Facilities
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GAO-08-544R:
United States Government Accountability Office:
Washington, DC 20548:
April 1, 2008:
The Honorable Herb Kohl:
Chairman:
Special Committee on Aging:
United States Senate:
The Honorable John D. Dingell:
Chairman:
Committee on Energy and Commerce:
House of Representatives:
Subject: Status of Implementation of GAO Recommendations on Evacuation
of Transportation-Disadvantaged Populations and Patients and Residents
of Health Care Facilities:
Many of the approximately 100,000 people who did not evacuate before
Hurricane Katrina struck the Gulf Coast in 2005 lacked access to a
vehicle. In the aftermath of the storm, questions were raised about how
well federal, state, and local governments were prepared to evacuate
such transportation-disadvantaged populations. Hurricane Katrina, which
ultimately resulted in over 1,300 deaths, also demonstrated
difficulties for evacuating hospital patients and nursing home
residents and raised questions about the role of the federal government
in assisting in such evacuations. While responding to disasters and
managing evacuations is largely a state and local responsibility, the
federal government can provide assistance when state and local
governments are overwhelmed. The federal government also provides
grants and technical assistance for disaster preparedness.
In January 2008, the Department of Homeland Security (DHS) released the
National Response Framework (NRF)--replacing the National Response
Plan. Its annexes detail the roles and responsibilities of local,
state, and federal agencies during emergencies.[Footnote 1] The Federal
Emergency Management Agency (FEMA), within DHS, is the lead
coordinating agency for federal emergency assistance. The NRF details
the responsibilities of supporting federal agencies, including the
Department of Transportation (DOT), whose responsibilities include
coordinating the restoration and recovery of transportation systems and
infrastructure, and the Department of Health and Human Services (HHS),
whose responsibilities include coordinating public health and medical
services. The federal government can provide medical resources, such as
emergency medical care and the evacuation of hospital patients during
disasters, through the National Disaster Medical System (NDMS), a
partnership of DHS, the Department of Defense, the Department of
Veterans Affairs, and HHS.
In 2006, we issued two reports addressing the evacuation of
transportation-disadvantaged populations and patients and residents of
health care facilities.[Footnote 2]
* Our December 2006 report addressed the preparedness of state and
local governments to evacuate transportation-disadvantaged populations
and gaps that existed in federal assistance. The highlights of that
report are shown in enclosure I, and the complete report may be found
at [hyperlink, http://www.gao.gov/new.items/d0744.pdf]. Our December
2006 report made three recommendations to the Secretary of DHS and one
recommendation to the Secretary of DOT.[Footnote 3]
* Our July 2006 report addressed the challenges faced by hospital and
nursing home administrators in evacuating patients and residents of
health care facilities and limitations in the design of NDMS that need
clarification. The highlights of that report are shown in enclosure II,
and the complete report may be found at [hyperlink,
http://www.gao.gov/new.items/d06826.pdf]. Our July 2006 report made two
recommendations to the Secretary of DHS.[Footnote 4]
Recently, you expressed concerns about the extent to which our
recommendations have been implemented and asked us to assess the
progress these agencies have made in doing so. To address your
concerns, we reviewed relevant agency documentation, including reports,
planning guidance, and program documentation, and interviewed officials
at DHS, DOT, and HHS. We conducted this performance audit from October
2007 to March 2008 in accordance with generally accepted government
auditing standards. Those standards require that we plan and perform
the audit to obtain sufficient, appropriate evidence to provide a
reasonable basis for our findings and conclusions based on our audit
objectives. We believe that the evidence obtained provides a reasonable
basis for our findings and conclusions based on our audit objectives.
Summary:
We found that progress implementing our recommendations has been mixed.
Of the six recommendations contained in the two reports, two
recommendations have been substantially implemented, while three
recommendations have been partially implemented, and one recommendation
has not been implemented.
Table 1 summarizes the six recommendations made in the two reports and
the status of implementation. We provided a briefing to your staffs in
February 2008 on the status of the implementation of these
recommendations. That briefing provides additional details on the
actions DHS, DOT, and HHS have taken and may be found in enclosure III
of this report.
Table 1: GAO Recommendations and Status of Implementation:
DHS: Clarify, in the National Response Plan, that FEMA is the lead and
coordinating agency for providing evacuation assistance when state and
local governments are overwhelmed and also clarify the responsibilities
of supporting federal agencies. (See enc. III, slide 8.)
Partially implemented.
DHS: Require that, as part of DHS grant programs, state and local
governments plan, train, and conduct exercises for the evacuation of
transportation-disadvantaged populations. (See enc. III, slide 9.)
Not implemented.
DHS: Improve technical assistance to state and local governments by (a)
providing more detailed guidance on how to plan, train, and conduct
exercises for evacuating transportation-disadvantaged populations and
(b) improving the organization and search functions of its online
information sharing portal used by federal, state, and local officials.
(See enc. III, slides 10 and 11).
Partially implemented.
DOT: Encourage the department's grant recipients and stakeholders to
share information that would assist emergency management and
transportation officials in identifying and locating, as well as
determining the evacuation needs of and providing transportation for,
transportation- disadvantaged populations. (See enc. III, slide 12.)
Substantially implemented.
HHS and DHS[A]: Clearly delineate how the federal government will
assist state and local governments with moving patients and residents
from hospitals and nursing homes to a mobilization center, where NDMS
transportation begins. (See enc. III, slide 16.)
Substantially implemented.
HHS and DHS[A]: In consultation with the other NDMS partners, clearly
delineate how to address the needs of nursing home residents during
evacuations, including the arrangements necessary to relocate these
residents. (See enc. III, slide 17.)
Partially implemented.
Source: GAO Analysis:
[A] In January 2007, the Pandemic and All-Hazards Preparedness Act
transferred primary authority for NDMS from DHS to HHS. Our July 2006
report made these recommendations to DHS, but HHS and DHS are
collaborating to implement them.
[End of table]
Agency Comments and Our Evaluation:
We provided a draft of this report to the Secretaries of DHS, DOT, and
HHS. The Department of Transportation provided written comments that we
incorporated as appropriate and Health and Human Services did not
provide any comments. The Department of Homeland Security provided
written comments in response to our draft, which are reproduced in
enclosure IV. DHS disagreed with our assessment that it "did not
implement" GAO's recommendation that DHS require that, as part of its
grant programs, state and local governments plan, train, and conduct
exercises for the evacuation of transportation-disadvantaged
populations. DHS stated that it has taken a number of steps to address
this recommendation, including: defining "special needs populations" in
the NRF and integrating special needs populations considerations
throughout the NRF; developing guidance documents to assist state,
local, and tribal emergency management managers meet the needs of
special needs populations; and incorporating special needs
considerations into DHS grant guidance. We recognize the efforts that
DHS has taken to address these issues and agree that DHS has taken
steps to increase awareness and consideration of transportation-
disadvantaged population issues. However, DHS does not require that
grant recipients plan, train, and conduct exercises for the evacuation
of transportation-disadvantaged populations, as stated in our
recommendation. We therefore continue to maintain that DHS has not
implemented this recommendation.
As agreed with your offices, unless you publicly announce the contents
of this report earlier, we plan no further distribution until 30 days
from the date of this letter. At that time, we will send copies of this
report to interested congressional committees and to the Secretaries of
DHS, DOT, and HHS. We will also make copies available to others upon
request. In addition, this report will be available at no charge on
GAO's web site, [hyperlink, http://www.gao.gov].
If you or your staff have any questions on matters discussed in this
report, please contact David Wise at (202) 512-5731 or wised@gao.gov
for issues related to transportation-disadvantaged populations or
Cynthia A. Bascetta at (202) 512-7207 or bascettac@gao.gov for issues
related to hospitals and nursing homes. Contact points for our Offices
of Congressional Relations and Public Affairs may be found on the last
page of this report. Key contributors to this report include Steve
Cohen, Assistant Director; Linda Kohn, Assistant Director; Colin
Fallon; Marisa London; Matthew Rosenberg; and Will Simerl.
Signed by:
David Wise:
Acting Director, Physical Infrastructure Issues:
Signed by:
Cynthia A. Bascetta:
Director, Health Care:
[End of correspondence]
Enclosures:
Enclosure I: Highlights of GAO-07-44:
GAO Highlights:
Highlights of GAO-07-44, a report to congressional committees.
Why GAO Did This Study:
During the evacuation of New Orleans in response to Hurricane Katrina
in 2005, many of those who did not own a vehicle and could not evacuate
were among the over 1,300 people who died. This raised questions about
how well state and local governments, primarily responsible for
disaster planning, integrate transportation-disadvantaged populations
into such planning. GAO assessed the challenges and barriers state and
local officials face; how prepared these governments are and steps they
are taking to address challenges and barriers; and federal efforts to
provide evacuation assistance. GAO reviewed evacuation plans;
Department of Homeland Security (DHS), Department of Transportation
(DOT), and other studies; and interviewed officials in five major city
and four state governments.
What GAO Found:
State and local governments face evacuation challenges in identifying
and locating transportation-disadvantaged populations, determining
their needs, and providing for their transportation. These populations
are diverse and constantly changing, and information on their location
is often not readily available. In addition, these populations‘
evacuation needs vary widely; some require basic transportation while
others need accessible equipment, such as buses with chair lifts. Legal
and social barriers impede addressing these evacuation challenges. For
example, transportation providers may be unwilling to provide
evacuation assistance because of liability concerns.
State and local governments are generally not well prepared”in terms of
planning, training, and conducting exercises”to evacuate transportation-
disadvantaged populations, but some have begun to address challenges
and barriers. For example, DHS reported in June 2006 that only about 10
percent of state and about 12 percent of urban area emergency plans it
reviewed adequately addressed evacuating these populations.
Furthermore, in one of five major cities GAO visited, officials
believed that few residents would require evacuation assistance despite
the U.S. Census reporting 16.5 percent of car-less households in that
major city. DHS also found that most states and urban areas
significantly underestimated the advance planning and coordination
required to effectively address the needs of persons with disabilities.
Steps being taken by some such governments include collaboration with
social service and transportation providers and transportation planning
organizations”some of which are DOT grantees and stakeholders”to
determine transportation needs and develop agreements for emergency use
of drivers and vehicles.
The federal government provides evacuation assistance to state and
local governments, but gaps in this assistance have hindered many of
these governments‘ ability to sufficiently prepare for evacuations.
This includes the lack of any specific requirement to plan, train, and
conduct exercises for the evacuation of transportation-disadvantaged
populations as well as gaps in the usefulness of DHS‘s guidance.
Although federal law requires that state and local governments with
mass evacuation plans incorporate special needs populations into their
plans, this requirement does not necessarily ensure the incorporation
of all transportation-disadvantaged populations. Additionally, while
DHS has made improvements to an online portal for sharing related
information, this information remains difficult to access because of
poor search and organizational functions. Moreover, although the
federal government can provide evacuation assistance when state and
local governments are overwhelmed, the federal government is not
prepared to do so. Amendments to the Stafford Act in October 2006
affirmed that FEMA (an agency within DHS) is responsible for leading
and coordinating evacuation assistance. DHS has not yet clarified, in
the National Response Plan, the lead, coordinating, or supporting
agencies in such cases.
What GAO Recommends:
DHS should clarify federal agencies‘ roles and responsibilities for
providing evacuation assistance when state and local governments are
overwhelmed. DHS should require state and local evacuation preparedness
for transportation-disadvantaged populations and improve information to
assist these governments. DOT should encourage its grant recipients to
share information to assist in evacuation preparedness for these
populations. DOT and DHS agreed to consider our recommendations, and
DHS stated it has partly implemented some of them.
[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-44].
To view the full product, including the scope and methodology, click on
the link above. For more information, contact Kate Siggerud at (202)
512-2834 or SiggerudK@gao.gov.
[End of enclosure]
Enclosure II: Highlights of 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 enclosure]
Enclosure III: Briefing on the Status of GAO Recommendations:
Transportation-Disadvantaged Populations:
Status of Implementation of GAO Recommendations:
Briefing for Staff:
Special Committee on Aging, U.S. Senate:
Committee on Energy and Commerce:
House of Representatives:
February 5, 2008:
Overview:
* Objective, Scope, and Methodology;
* Status of Implementation of Recommendations;
* December 2006 report: Transportation-Disadvantaged Populations:
Actions Needed to Clarify Responsibilities and Increase Preparedness
for Evacuations:
- Objectives;
- Findings;
- Recommendations;
- Status of implementation of recommendations.
* July 2006 report: Disaster Preparedness: Limitations in Federal
Evacuation Assistance for Health Facilities Should be Addressed:
- Objectives;
- Findings;
- Recommendations;
- Status of implementation of recommendations.
Objective, Scope, and Methodology:
Objective: To follow up on recommendations made to DHS and DOT
regarding the evacuation of transportation-disadvantaged populations.
[Footnote 5]
Scope: DHS, DOT, and HHS progress since our December 2006 and July 2006
reports.
Methodology: Collected and analyzed relevant documentation, such as
reports, planning guidance, and program documentation pertaining to
actions addressing our recommendations. Met with relevant officials at
DHS, DOT, and HHS.
We conducted this performance audit from October 2007 to February 2008
in accordance with generally accepted government auditing standards.
Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives.
Table: Status of Implementation of Recommendations:
DHS: Clarify Roles in National response Plan;
Partially implemented.
DHS: Require grant recipients to plan, train, and conduct evacuation
exercises;
Not implemented.
DHS: technical assistance to facilitate information sharing;
Partially implemented.
DOT: Encourage grant recipients to share information;
Partially implemented.
HHS: Clarify Roles in Moving Patients and Residents;
Substantially implemented.
HHS: Clarify How to Address Nursing Home Residents' Needs;
Substantially implemented.
Source: GAO.
[End of table]
Evacuation of Transportation-Disadvantaged Populations”Reporting
Objectives:
* What challenges do state and local governments face in preparing for
the evacuation of transportation-disadvantaged populations?
* How prepared are state and local governments to evacuate
transportation-disadvantaged populations?
* How has the federal government assisted state and local governments
in evacuating transportation-disadvantaged populations?
[from GAO, Transportation-Disadvantaged Populations: Actions Needed to
Clarify Responsibilities and Increase Preparedness for Evacuations, GAO-
07-44 (Washington, D.C.: Dec. 22, 2006)]
Evacuation of Transportation-Disadvantaged Populations”Report Findings:
* Challenges include difficulty in identifying and locating
transportation-disadvantaged populations, as well as legal and social
barriers.
* State and local governments are generally not well prepared to
evacuate transportation-disadvantaged populations.
*While the federal government assists state and local governments in
evacuations, gaps exist in federal assistance.
[from GAO, Transportation-Disadvantaged Populations: Actions Needed to
Clarify Responsibilities and Increase Preparedness for Evacuations, GAO-
07-44 (Washington, D.C.: Dec. 22, 2006)]
Evacuation of Transportation-Disadvantaged Populations”Report
Recommendations:
To DHS:
1) Clarify, in the National Response Plan, that FEMA is the lead and
coordinating agency to provide evacuation assistance when state and
local governments are overwhelmed, and also clarify the supporting
federal agencies and their responsibilities.
2) Require that, as part of its grant programs, all state and local
governments plan, train, and conduct exercises for the evacuation of
transportation-disadvantaged populations.
3) Improve technical assistance by (1) working with DOT to provide more
detailed guidance and technical assistance on how to plan, train, and
conduct exercises for evacuating transportation-disadvantaged
populations; and (2) continuing to improve the organization of and
search functions for its Lessons Learned Information Sharing online
portal to better facilitate access to information on evacuations of
transportation-disadvantaged for federal, state, and local officials.
To DOT:
4) Encourage DOT‘s grant recipients and stakeholders, through guidance
and outreach, to share information that would assist emergency
management and transportation officials in identifying and locating, as
well as determining the evacuation needs of and providing
transportation for, transportation-disadvantaged populations.
[from GAO, Transportation-Disadvantaged Populations: Actions Needed to
Clarify Responsibilities and Increase Preparedness for Evacuations, GAO-
07-44 (Washington, D.C.: Dec. 22, 2006)]
Recommendation 1: Clarification of Roles in National Response Plan:
* Partially Implemented. Draft Mass Evacuation Incident Annex to the
National Response Framework appears to clarify role of FEMA and
supporting federal agencies.
- Draft Mass Evacuation Annex designates FEMA as lead in providing
evacuation support when federal assistance is required, clarifies the
role of supporting federal agencies, and recognizes the need for
planning for persons with special needs.
- Ongoing GAO work examining clarification of other roles and
responsibilities in NRF.
* Responsibility for transportation services contracts and evacuation
transportation services transferred from DOT to DHS in early 2008.
Recommendation 2: Grants and State and Local Evacuation Exercises:
* Not Implemented. DHS does not require grantees to plan, train, or
conduct exercises on the evacuations of transportation-disadvantaged
populations, though stresses importance in Homeland Security Grant
Program (HSGP) guidance.
* FY 2007 HSGP guidance includes evacuation planning and special needs
populations as part of a ’focus area.“
* No requirements in other DHS grant programs, though funds can be used
for such purposes.
* DHS can only track grant fund expenditures by broad Target Capability
List categories, such as ’Citizen Evacuation and Shelter-In-Place“ or
’Planning.“
Recommendation 3: Technical Assistance to Facilitate Information
Sharing:
* Partially Implemented. DHS has developed basic guidance on the
evacuation of special needs populations and is currently working on
targeted guidance for states and localities.
* Planning guide series provides general guidance to state and local
governments:
- Special Needs Planning Guide;
- Evacuation Guide.
* Gap analysis (a survey of the needs, capabilities, and shortfalls in
state and local emergency preparedness):
- Survey and conduct workshops with emergency response officials about
needs, capabilities, and gaps;
- Action plan development to address gaps;
- Focus on sheltering and care of special needs populations, but only
limited focus on evacuation of special needs populations.
* Partially Implemented. DHS has improved organization and search
function of its Lessons Learned Information System, though technical
and functional problems remain.
* Improvements:
- Improved search functions and capability;
- Search results better organized and more relevant;
- Content improved.
* Problems remain:
- Content has not been added;
- Technical issues.
Recommendation 4: Encourage DOT Grant Recipients and Stakeholders to
Share Information:
* Substantially Implemented. Multiple DOT initiatives and guidance
encourage information sharing, including:
- Transportation Equity Research Program;
- Conferences and Workshop Series on Evacuation Primers;
- FHWA Final Rule on Safety in Transportation Planning.
* Although DOT has substantially implemented this recommendation, it
does not have a formal system to:
- distribute resources to grant recipients and stakeholders;
- track planning efforts for transportation-disadvantaged populations
at state and local levels.
Evacuation of Health Facilities Report”Reporting Objectives:
* What challenges do hospital and nursing home administrators face in
hurricanes?
* What limitations exist in the design of the National Disaster Medical
System (NDMS), a partnership of four federal agencies, to assist with
health facility evacuation?
* What are the federal requirements for hospital and nursing home
disaster and evacuation planning?
[From GAO, Disaster Preparedness: Limitations in Federal Evacuation
Assistance for Health Facilities Should be Addressed, GAO-06-826
(Washington, D.C.: July 20, 2006)]
Evacuation of Health Facilities Report”Report Findings:
* Facility administrators generally sheltered in place but had to have
adequate supplies in order to do so. When evacuating, facility
administrators had problems securing transportation because of supply
shortages and had problems with communication systems.
* NDMS and other federal programs were not designed to move patients or
residents from facilities to a mobilization center where NDMS
transportation could begin.
* NDMS was not configured to evacuate people with special needs who do
not require hospitalization, including nursing home residents.
[From GAO, Disaster Preparedness: Limitations in Federal Evacuation
Assistance for Health Facilities Should be Addressed, GAO-06-826
(Washington, D.C.: July 20, 2006)]
Evacuation of Health Facilities Report”Report Recommendations:
To DHS:
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 NDMS
transportation begins.
2) 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.
* Under the Pandemic and All-Hazards Preparedness Act, primary
authority for NDMS was transferred from DHS to HHS in January 2007. HHS
and DHS are collaborating to implement both recommendations.
[From GAO, Disaster Preparedness: Limitations in Federal Evacuation
Assistance for Health Facilities Should be Addressed, GAO-06-826
(Washington, D.C.: July 20, 2006)]
Recommendation 1: Delineate Role of the Federal Government in Moving
Patients and Residents from Health Facilities to Mobilization Centers:
* Substantially Implemented. HHS and DHS collaborated with state and
local departments of health in hurricane-prone regions to determine
gaps between needs and available resources for hospital and nursing
home evacuations and to determine local, state, or federal resources to
fill the gaps.
* Based on this analysis, HHS and DHS contracted for ground and air
ambulances and para-transit services for Gulf and East Coast states.
* HHS encouraged states to establish regional coalitions for mutual
aid.
* HHS has completed a hurricane ’playbook“ that improves the clarity of
the role of federal assistance in evacuations.
Recommendation 2: Delineate How to Address Nursing Home Residents‘
Needs:
* Partially Implemented. Nursing homes were included as part of the
HHS, DHS, and state and local health department analysis of gaps and
how to fill those gaps.
* Vehicles obtained under HHS and DHS contracts”particularly para-
transit vehicles”could be used to evacuate nursing home residents.
* The federal role in the evacuation of nursing home residents is not
specifically addressed in HHS‘s hurricane ’playbook.“
* HHS has not provided evidence that it has clarified the role of NDMS
in evacuating nursing home residents.
[End of enclosure]
Enclosure IV: Comments from the Department of Homeland Security:
Homeland Security:
March 19, 2008:
Mr. David Wise:
Acting Director:
Physical Infrastructure Issues:
Ms. Cynthia A. Bascetta:
Director, Health Care:
U.S. Government Accountability Office:
441 G Street, NW:
Washington, DC 20548:
Dear Mr. Wise and Ms. Bascetta:
RE: Draft Report 08-544R titled Status of Implementation of GAO
Recommendations on Evacuation of Transportation-Disadvantaged
Populations and Patients and Residents of Health Care Facilities (GAO
Job Code 541037):
The Department of Homeland Security (DHS) appreciates the opportunity
to review and comment on the draft report referenced above. The report
discusses the status of implementation of recommendations contained in
two previously issued U.S. Government Accountability Office (GAO)
reports.
GAO made three recommendations to the Secretary of Homeland Security in
GAO-07-44, Transportation-Disadvantaged Populations: Actions Needed to
Clarify Responsibilities and Increase Preparedness for Evacuations. As
noted in Appendix III of the draft, DHS has partially implemented two
of the three recommendations, notably dealing with clarification of
agency roles dealing with mass evacuations and the provision of
technical assistance designed to facilitate information sharing. The
report asserts that DHS has not required that, as part of our grant
programs, all State and local governments plan, train, and conduct
exercises for the evacuation of transportation-disadvantaged
populations. We disagree with the last conclusion as action has been
taken to address the recommendation.
DHS's Office for Civil Rights and Civil Liberties (CRCL) and the
Federal Emergency Management Agency (FEMA) have been actively
collaborating in several areas relevant to the recommendation that DHS
"require grantees to plan, train, or conduct exercises on the
evacuations of transportation-disadvantaged populations." Highlights of
work geared towards improving grantee performance with regard to the
evacuation of transportation-disadvantaged populations include:
(1) The National Response Framework (NRF) now includes a definition for
the term "special needs." Special needs populations are defined as
populations whose members may have additional needs before, during, and
after an incident in functional areas, including but not limited to:
maintaining independence, communication, transportation, supervision,
and medical care. Individuals in need of additional response assistance
may include those who have disabilities; who live in institutionalized
settings; who are elderly; who are children; who are from diverse
cultures; who have limited English proficiency or are non-English
speaking; or who are transportation-disadvantaged.
Special needs considerations as defined above are well integrated
through the NRF base plan, Emergency Support Functions, and Annexes.
The inclusion of specific reference to transportation-disadvantaged
populations in the NRF will result in greater emphasis and commitment
to meeting the needs of members of this segment of the special needs
population. Additionally, the NRF delineates roles and responsibilities
of key emergency planning partners at the local, Tribal, State, and
Federal level. Among them is the responsibility to ensure that local
emergency plans take into account the needs of individuals with special
needs and the inclusion of special needs expertise such as groups that
provide specialized services for special needs populations.
(2) FEMA is working collaboratively with CRCL to revise the
standardized guidance for the development of emergency operations plans
(EOPS), the comprehensive preparedness guide (CPG) 101. CPG 101
provides emergency managers and other emergency services personnel with
DHS's best judgment and recommendations on how to address the entire
planning process. This guide helps State, local, and Tribal emergency
managers with their efforts to develop and maintain a viable all-hazard
emergency operation plan. Recommendations on strategies for meeting the
needs of special needs populations are being integrated in the revised
CPG 101. An emergency management planning guide for special needs
populations as defined in the NRF has been developed by FEMA in
collaboration with CRCL and will serve as one of the several CPG 101
companion documents. This soon to be released special needs planning
guide articulates detailed special needs planning considerations.
(3) DHS grant guidance incorporates special needs considerations
including, but not limited to the definition of special needs
populations, references to obligation under civil rights statutes, and
helpful special needs planning resources.
DHS continues to strongly encourage our State and local homeland
security partners to develop planning, training, and exercise
activities which help to strengthen preparedness efforts relative to
various homeland security priorities, including but not limited to
special needs populations. Our homeland security guidance has
identified the special needs population as a direct and distinct area
of emphasis that State and local governments should include when
considering overall preparedness including and efforts.
Historically, State and local units of government have developed
emergency operations plans which contain a separate annex/focus area
relative to special needs populations. State and local units of
government also have conducted training and exercises which often
contain a specific focus area directly relating to special needs
populations. However, because special needs considerations do not exist
in a vacuum they are typically integrated throughout other focus areas
such as mass evacuation, public notification, interoperable
communications, sheltering systems, and activation of primary and
secondary emergency and operations centers. This approach allows
responder communities to validate these numerous focus areas, overall
plans, and training received through exercises and serves to benefit a
greater good of accomplishing many requirements and priorities.
GAO made two recommendations to the Secretary in GAO-06-826, Disaster
Preparedness: Limitations in Federal Evacuation Assistance for Health
Facilities Should be Addressed. GAO found that DHS substantially
implemented the recommendation to delineate the role of the Federal
government in moving patients and residents from health facilities to
mobilization centers. GAO also found that DHS partially implemented the
recommendation on delineating how to address nursing home residents'
needs.
Thank you again for the opportunity to comment on this draft report and
we look forward to working with you on future homeland security issues.
Sincerely,
Signed by:
Steven J. Pecinovsky:
Director:
Departmental GAO/OIG Liaison Office:
[End of enclosure]
Footnotes:
[1] The NRF went into effect on March 22, 2008.
[2] Transportation-disadvantaged populations can include numerous
categories of people without personal vehicles, such as: the elderly
and persons with disabilities who have mobility impairments that
preclude them from driving or who need medical equipment in order to
travel; low-income, homeless, or transient persons who do not have a
permanent residence or who do not own or have access to a personal
vehicle; children without an adult present during a disaster; tourists
and commuters who are frequent users of public transportation; those
with limited English proficiency who tend to rely on public transit
more than English speakers; or those who, for any other reason, do not
own or have access to a personal vehicle.
[3] GAO, Transportation-Disadvantaged Populations: Actions Needed to
Clarify Responsibilities and Increase Preparedness for Evacuations, GAO-
07-44 (Washington, D.C.: Dec. 22, 2006).
[4] GAO, Disaster Preparedness: Limitations in Federal Evacuation
Assistance for Health Facilities Should be Addressed, GAO-06-826
(Washington, D.C.: July 20, 2006).
[5] Initial GAO recommendations were made to DHS regarding the
evacuation of health care facilities. Responsibility for these
functions was transferred from DHS to HHS in January 2007. HHS and DHS
are collaborating to implement both recommendations.
[End of section]
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