This is the accessible text file for GAO report number GAO-08-544R entitled 'Status of Implementation of GAO Recommendations on Evacuation of Transportation-Disadvantaged Populations and Patients and Residents of Health Care Facilities' which was released on April 29, 2008. This text file was formatted by the U.S. Government Accountability Office (GAO) to be accessible to users with visual impairments, as part of a longer term project to improve GAO products' accessibility. Every attempt has been made to maintain the structural and data integrity of the original printed product. Accessibility features, such as text descriptions of tables, consecutively numbered footnotes placed at the end of the file, and the text of agency comment letters, are provided but may not exactly duplicate the presentation or format of the printed version. The portable document format (PDF) file is an exact electronic replica of the printed version. We welcome your feedback. Please E-mail your comments regarding the contents or accessibility features of this document to Webmaster@gao.gov. This is a work of the U.S. government and is not subject to copyright protection in the United States. It may be reproduced and distributed in its entirety without further permission from GAO. Because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately. 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] GAO's Mission: The Government Accountability Office, the audit, evaluation and investigative arm of Congress, exists to support Congress in meeting its constitutional responsibilities and to help improve the performance and accountability of the federal government for the American people. GAO examines the use of public funds; evaluates federal programs and policies; and provides analyses, recommendations, and other assistance to help Congress make informed oversight, policy, and funding decisions. 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