In addition to  CMS requirements, JCAHO, AOA, and states can establish additional  requirements for hospitals and nursing homes. 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. When evacuations were needed, facility administrators said that they had  problems with transportation. 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. Although facility administrators reported having  contracts with transportation companies, competition for the same pool of  vehicles created supply shortages. 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. 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. 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. 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. 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. 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. 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. We also  noted that reliance on state and local resources was inadequate when  multiple facilities in a community had to evacuate simultaneously. 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 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. 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.
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.