Disaster Response: HHS Should Address Deficiencies Highlighted by Recent Hurricanes in the U.S. Virgin Islands and Puerto Rico
Fast Facts
The catastrophic destruction caused by Hurricanes Irma and Maria overwhelmed the U.S. Virgin Islands and Puerto Rican governments and resulted in a large federal disaster response.
The Department of Health and Human Services led federal public health and medical services efforts. Among other things, it provided medical personnel and facilities and evacuated critical care and dialysis patients.
We identified shortcomings in HHS’s efforts, such as insufficient staffing at emergency operations centers that contributed to confusion over the status of evacuated patients. We made 7 recommendations, including that HHS ensure adequate staffing.
HHS’s Disaster Medical Assistance Team Setting Up a Temporary Medical Clinic in Puerto Rico, October 2017
A team of people organizing boxes of supplies
Highlights
What GAO Found
The catastrophic destruction encountered as a result of Hurricanes Irma and Maria proved overwhelming to the U.S. Virgin Islands and Puerto Rican governments and resulted in a large federal disaster response, complicated by losses of power, communication, and health care infrastructure. The Department of Health and Human Services (HHS) led the federal public health and medical services response and undertook numerous actions to address the needs in the territories—including evacuating critical care and dialysis patients from the U.S. Virgin Islands and Puerto Rico and providing medical personnel and facilities.
However, GAO identified several shortcomings in HHS's leadership. While the scale, location, and timing of these storms complicated response efforts, the deficiencies GAO identified were in many cases a function of preparedness policies, or lack thereof. As a result, they could adversely affect future large-scale responses unless addressed. For example, as the lead agency, HHS is responsible for ensuring that appropriate planning activities are undertaken, including monitoring the federal ability to provide core public health and medical services response capabilities. However, GAO found that
HHS did not have a full understanding of the capabilities and limitations of its support agencies, including the Departments of Defense, Homeland Security, and Veterans Affairs. Consequently, HHS's needs were not always aligned with the resources that its support agencies could provide, resulting in some deployed resources not being properly and efficiently utilized. For example, HHS requested Department of Defense medical teams, but these teams specialized in trauma and surgical care, not the chronic and primary care needed.
HHS lacked plans for the territories that accounted for the chronic and primary care needs in isolated communities. This care was greatly needed, given that many, especially the elderly, could not easily access hospitals.
Example of Downed Power Lines in Puerto Rico, November 2017
Why GAO Did This Study
Hurricanes Irma and Maria hit the U.S. Virgin Islands and Puerto Rico within two weeks of each other in September 2017, causing catastrophic damage. HHS is responsible for leading the federal public health and medical services response during a disaster, such as these hurricanes. As part of its lead federal role during these hurricanes, HHS called upon support agencies, including the Departments of Defense, Homeland Security, and Veterans Affairs, to assist with the public health and medical services response.
GAO was asked to review the federal public health and medical services response to Hurricanes Irma and Maria in the U.S. Virgin Islands and Puerto Rico. This report examines HHS's actions and leadership of this response, among other things. GAO reviewed documentation on the preparedness for, and response to, the hurricanes. It also interviewed federal and territory officials and interviewed or received written responses from eight nonfederal stakeholders involved in the response, such as nongovernmental organizations. GAO identified these stakeholders through research and referrals.
Recommendations
GAO is making seven recommendations, including that HHS develop agreements with support agencies that include response capability and limitation information, and develop response plans for providing care in isolated communities. HHS disagreed with two of the seven citing, among other things, territory responsibility for plans. GAO clarified the intent of the two recommendations and believes that all seven are warranted.
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Office of the Assistant Secretary for Preparedness and Response |
Priority Rec.
ASPR should develop a response personnel strategy to ensure, at a minimum, a lead ASPR liaison officer is consistently at the local emergency operations center(s) during an emergency support functions (ESF) #8 response and another liaison, if not more, is at strategic location(s) in the area. (Recommendation 1) |
ASPR agreed with this recommendation. ASPR officials told us in May 2019, and reiterated in March 2021, February 2022, and January 2023 that their incident response framework includes a long-term goal of creating an incident response team that will establish an initial ESF#8 presence at local emergency operations centers and manage resources and capabilities. If implemented, this strategy may allow ASPR to provide more liaisons on the ground during a response and address the staffing deficiency we identified. As of January 2023, ASPR has added 100 intermittent federal employee positions to aid in future response operations and support coordination at the local and regional level. According to ASPR, these positions were added within each of the 10 HHS regions. The first round of hiring notices resulted in 46 selections of qualified applicants. The second round resulted in 44 selections and personnel started in positions in September 2021. As of January 2023, ASPR officials stated that one primary responsibility of these personnel is supporting emergency operations centers as and when needed, and that they have few vacancies. This fulfills the intent of the recommendation.
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| Office of the Assistant Secretary for Preparedness and Response | As ASPR finalizes its federal patient movement framework, the agency should exercise the framework with its National Disaster Medical System (NDMS) partners to ensure that patients evacuated through NDMS will be consistently tracked from the start of their evacuation. (Recommendation 2) |
The U.S. Department of Health and Human Services (HHS) concurred with the recommendation GAO made in September 2019. As of February 2024, HHS stated that the federal patient movement framework was exercised via a real-world event in 2020 in support of COVID-19 response operations originating in Asia. HHS's Air Medical Evacuation teams, which are part of the National Disaster Medical System (NDMS), directly supported 39 flights, moving over 2,000 individuals who tested positive for COVID-19, individuals under observation, or individuals who were asymptomatic. According to HHS officials, all movement was tracked via HHS' Joint Patient Assessment and Tracking System. HHS also stated it exercised the federal patient movement framework with NDMS partners during scheduled exercises, including Ultimate Caduceus 2022, and Patriot North. As of January 2023, ASPR officials explained that these exercises were done jointly with the Department of Defense (DoD), with DoD as the lead. HHS provided a Memorandum for Record on the Ultimate Caduceus 2023 exercise that was held in March 2023. The Memorandum included an overview of the exercise, participants, objectives, metrics, and conclusions from the exercise. The Memorandum also shows that the federal patient movement framework was successful in ensuring patients evacuated through NDMS were consistently tracked from the start of the evacuation through to the final point of care.
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| Office of the Assistant Secretary for Preparedness and Response | ASPR should put controls in place to ensure data on all NDMS evacuated patients are complete and accurate. (Recommendation 3) |
HHS officials concurred with this recommendation. In February 2022, ASPR officials stated that they hired a nurse consultant into NDMS who is the lead for the case management program. As of February 2024, HHS reported that JPATS controls for ensuring patient data are complete and accurate relies heavily on team-inputted checks and balances, together with other agencies, to support validation of patient status. The following are steps taken to check and validate patient data utilizing JPATS during an evacuation. According to HHS, these JPATS steps and processes were utilized in the Ultimate Caduceus 2023 exercise and proved successful in ensuring patients evacuated through NDMS were consistently tracked from the start of the evacuation through to the final point of definitive care. GAO will leave this recommendation open until we receive documentation of when these controls were put in place.
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| Office of the Assistant Secretary for Preparedness and Response | ASPR Region II should revise its Incident Response Plans for the territories to include strategies for providing chronic and primary care in isolated communities. These strategies could include the incorporation of Federally Qualified Health Centers and other local health clinics as part of a response. (Recommendation 4) |
HHS stated in 2019 and reiterated in March 2021 that it does not concur with this recommendation. In its comments on the draft report, HHS stated that while ASPR has federal plans in place that guide federal response, each state and locality is responsible for developing its own individual plans. As of January 2023, ASPR officials explained that they have held meetings with the Puerto Rico Governor's office, Puerto Rico Dept. of Health, Public Health emergency preparedness, the VA, FEMA, and PREMB. On December 7, 2022, ASPR officials also provided documentation of the coordination of a "hub and spoke model," developed during Hurricane Maria and finalized during the recovery phase. This "hub and spoke model" defines how each medical center could move patients and resources during a disaster. It identifies "Hub" facilities that have capacity to absorb surge from the "spoke" hospitals, including remote facilities. ASPR officials provided documentation that this model was discussed with multiple regional officials between February 2021 and February 2022. During this timeframe, ASPR officials also assisted regions with identifying areas needing collaboration, putting mutual aid agreements in place, and holding technical assistance meetings and exercises to identify implementation challenges and ensure lines of communication were open. This fulfills the intent of the recommendation.
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| Office of the Assistant Secretary for Preparedness and Response |
Priority Rec.
ASPR should work with support agencies to develop and finalize memorandums of agreement that include information on the capabilities and limitations of these agencies to meet ESF#8 core capabilities. (Recommendation 5) |
In its comments on the draft report and subsequently in May 2021 and January 2023, the U.S. Department of Health and Human Services (HHS) stated it did not concur with this September 2019 recommendation. In 2023, HHS responded that the National Response Framework articulates how ESFs operate during incident response, and that further agreements are not needed to outline functions and responsibilities. In addition, HHS stated it does not plan to develop a list of capabilities because capabilities can change, and due to the structure of the National Response Framework, all agency partners can quickly come together during a response to collaborate and coordinate resources. Despite disagreeing with the recommendation, in February 2024, HHS reported that it established several Interagency Agreements with federal partners to ensure they fully understand the capabilities ASPR may need during a response. HHS provided copies of agreements with both FEMA and DOD, which were signed and dated by officials in July 2022 and July 2021, respectively.
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| Office of the Assistant Secretary for Preparedness and Response | ASPR should develop a strategy demonstrating how it ESF#8 core capabilities can be provided through HHS and ESF#8 support agencies if DOD's capacity to respond is limited. (Recommendation 6) |
The U.S. Department of Health and Human Services (HHS) concurred with this September 2019 recommendation. In February 2024, HHS reported that ASPR has focused on establishing overarching surge contracts to augment the National Defense Medical System (NDMS) and its affiliated capabilities to include coordinating support resources through the ESF#8 Council. ASPR has formalized frequent meetings with the ESF#8 Council, which occurs every Wednesday, to adjudicate any ESF#8 response requirements and maintain collaboration throughout the year. Additional efforts made prior to an emergency to ensure ESF#8 core capabilities can be provided through HHS and support agencies if DOD's capacity to respond is limited. According to HHS, this included providing surge capabilities to areas that generally DOD had resources constraints in supporting, such as medical staffing and logistics resources, by establishing a suite of agreements and contracts. For example, HHS provided documentation supporting that, in March 2022, ASPR established an interagency agreement with GSA to provide continental U.S. and international transportation capabilities.
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| Office of the Assistant Secretary for Preparedness and Response | ASPR should take steps to ensure the perspectives of key external parties are incorporated in the development of HHS's after-action reviews, following future ESF#8 activations. (Recommendation 7) |
The U.S. Department of Health and Human Services (HHS) concurred with the recommendation GAO made in September 2019. As of January 2023, HHS officials stated that, since GAO's last update, the Assistant Secretary for Preparedness and Response's (ASPR's) Exercise Evaluation and After Action Team has a standing corrective action collaboration with the Centers for Disease Control and Prevention as well as the Federal Emergency Management Agency's Continuous Improvement Program to share data and observations for collaborative events and responses. HHS officials stated that, as conditions warrant, the Exercise Evaluation and After Action Team expands these collaborations for ongoing data sharing with the interagency collaboration. In addition, as of February 2024, HHS reported that ASPR's After-Action Program does conduct interviews with all relevant partners, such as external parties, to include their input. HHS provided documentation of this by sharing the methodology section of the draft HHS Response to COVID-19 After-Action Report: SLTT Perspectives. This document states that part of the methodology used for the report involved interviewing officials from SLTTs and identifying recommended improvement actions.
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