United Stat es 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.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 1The NRF went into effect on March 22, 2008. GAO-08-544R Transportation-Disadvantaged Populations 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.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 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.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 http://www.gao.gov/new.items/d06826.pdf. Our July 2006 report made two recommendations to the Secretary of DHS.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. This report makes no new recommendations. 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. 2Transportation-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. 3GAO, Transportation-Disadvantaged Populations: Actions Needed to Clarify Responsibilities and Increase Preparedness for Evacuations, GAO-07-44 (Washington, D.C.: Dec. 22, 2006). 4GAO, Disaster Preparedness: Limitations in Federal Evacuation Assistance for Health Facilities Should be Addressed, GAO-06-826 (Washington, D.C.: July 20, 2006). Pag e 2 GAO-08-544R Transportation-Disadvantaged Populations 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 Substantially Partially Not implemented implemented implemented 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.) 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.) 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.) 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.) HHS and DHSa 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.) 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.) Source: GAO. aIn 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. 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 technical 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 Pag e 3 GAO-08-544R Transportation-Disadvantaged Populations 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 at 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 [email protected] for issues related to transportation-disadvantaged populations or Cynthia A. Bascetta at (202) 512-7207 or [email protected] 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. David J. Wise Acting Director, Physical Infrastructure Issues Cynthia A. Bascetta Director, Health Care Enclosures Pag e 4 GAO-08-544R Transportation-Disadvantaged Populations Enclosure I: Highlights of GAO-07-44 Pag e 5 GAO-08-544R Transportation-Disadvantaged Populations Enclosure II: Highlights of GAO-06-826 Pag e 6 GAO-08-544R Transportation-Disadvantaged Populations 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 Pag e 7 GAO-08-544R Transportation-Disadvantaged Populations Overview (cid:127) Objective, Scope, and Methodology (cid:127) Status of Implementation of Recommendations (cid:127) December2006report:Transportation-Disadvantaged Populations: Actions Needed to Clarify Responsibilities and Increase Preparedness forEvacuations (cid:127) Objectives (cid:127) Findings (cid:127) Recommendations (cid:127) Status of implementation of recommendations (cid:127) July 2006 report:Disaster Preparedness: Limitations in Federal Evacuation Assistance for Health Facilities Should be Addressed (cid:127) Objectives (cid:127) Findings (cid:127) Recommendations (cid:127) Status of implementation of recommendations 2 Pag e 8 GAO-08-544R Transportation-Disadvantaged Populations Objective, Scope, and Methodology Objective: To follow up on recommendations made to DHS and DOT regarding the evacuation of transportation-disadvantaged populations1 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. 1 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 3 recommendations. Pag e 9 GAO-08-544R Transportation-Disadvantaged Populations Status of Implementation of Recommendations 4 Pag e 10 GAO-08-544R Transportation-Disadvantaged Populations