Disaster Response: HHS Should Address Deficiencies Highlighted by Recent Hurricanes in the U.S. Virgin Islands and Puerto Rico

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.

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.

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.

In 2017, two major hurricanes devastated the U.S. Virgin Islands and  Puerto Rico within 2 weeks of each other. On September 6, 2017,  Hurricane Irma passed by the U.S. Virgin Islands, delivering wind gusts in  excess of 100 miles per hour, and on September 20, 2017, Hurricane  Maria passed by the U.S. Virgin Islands and made landfall on Puerto  Rico, delivering wind gusts in excess of 155 miles per hour. These storms  resulted in both territories experiencing extensive power outages and a  loss of clean water, telecommunication systems, and transportation  systems, including roads, bridges, ports, and airport runways. The extent  of the damage from these hurricanes resulted in large-scale and complex  response operations.

Such large-scale and complex responses may be more common given  that, according to a 2018 report from the U.S. Global Change Research  Program, extreme weather and climate-related events are expected to  increase in frequency and intensity. According to this report, the expected  increase in extreme weather events will further burden the U.S. energy  system, thus amplifying the risk of more frequent and longer-lasting  power outages and fuel shortages that could affect access to medical  care.

The National Response Framework establishes an all-hazards response  structure to coordinate federal resources during hurricanes and other  emergencies and disasters and is divided into 14 emergency support  functions (ESF): functional areas that are most frequently needed during  a national response. While the Federal Emergency Management Agency  (FEMA), an agency within the Department of Homeland Security, leads  the overall federal response during emergencies and disasters, the Office  of the Assistant Secretary for Preparedness and Response (ASPR), an  agency within the Department of Health and Human Services (HHS), is the lead agency for ESF#8—the public health and medical services  response. As such, ASPR led the federal public health and medical  services response to Hurricanes Irma and Maria in the U.S. Virgin Islands  and Puerto Rico. As part of its lead role in this response, ASPR  coordinated assistance from other federal agencies—referred to as  ESF#8 support agencies—including FEMA, the Department of Defense  (DOD), and the Department of Veteran Affairs (VA).

You asked us to review the federal government’s preparedness,  response, and recovery efforts related to the 2017 natural disasters. As  part of that effort, we are conducting a broader body of work covering  various disaster response and recovery issues. Work published to date  can be found in the Related GAO Products section of this report, and we  will continue to report on these issues over the next year.

This report examines ASPR’s actions as the ESF#8 lead in the federal  response to Hurricanes Irma and Maria in U.S. Virgin Islands and Puerto  Rico. Specifically, our objectives were to  (1) describe the ASPR-led public health and medical services response to  Hurricanes Irma and Maria in the U.S. Virgin Islands and Puerto Rico,  (2) examine ASPR’s leadership of the public health and medical services  response, and  (3) examine steps ASPR has taken to evaluate its response actions.

To describe the ASPR-led public health and medical services response to  Hurricanes Irma and Maria in the U.S. Virgin Islands and Puerto Rico, we  reviewed documentation outlining ASPR’s response activities and  interviewed officials involved in the response. To identify the specific  response activities taken by ASPR and its ESF#8 support agencies, we  reviewed ASPR Situation Reports, FEMA Situation Reports, and  Department of Interior Senior Leadership Briefings, which were daily  reports that provided ESF federal response agencies with the current  response status. We also reviewed other documentation, such as FEMA  and VA hurricane after-action reports, and federal agency press releases  that contained information on response activities. We interviewed ASPR,  FEMA, DOD, and VA officials to supplement the information we collected  through our review of response documentation. Because this review  focused on ASPR’s response activities, it generally does not include  actions taken by other HHS agencies, such as the Centers for Disease  Control and Prevention, the Food and Drug Administration, and the  Health Resources & Services Administration.

To examine ASPR’s leadership of the public health and medical  response, we reviewed documentation and interviewed officials involved  in the response. Specifically, we reviewed documentation describing  challenges encountered during the response, including FEMA, DOD, VA,  Puerto Rico, and U.S. Virgin Islands hurricane after-action reports. We  also reviewed documentation on preparedness actions taken prior to the  hurricanes, such as HHS agreements with its ESF#8 support agencies  and its Incident Response Plans for the U.S. Virgin Islands and Puerto  Rico, as well as available documentation on any steps taken to mitigate  identified challenges. Additionally, we interviewed ASPR, FEMA, DOD,  VA, and Department of Interior officials to identify response challenges.  We interviewed ASPR and FEMA officials at the Headquarters level who  were involved in the response, as well as those at Region II—the Region  that is the liaison to the U.S. Virgin Islands and Puerto Rico.

Further, we conducted site visits to the U.S. Virgin Islands and Puerto  Rico. In the U.S. Virgin Islands, we interviewed territory officials from the  Department of Health, Department of Human Services, and Office of  Inspector General. In Puerto Rico, we interviewed territory officials from  the Emergency Management Agency, the Secretary of the Department of  Health, and officials in the Department of Health’s Office of Public Health  and Preparedness and Response. We also interviewed stakeholders from  the U.S. Virgin Islands and Puerto Rico involved in the response.  Specifically, in the U.S. Virgin Islands, we interviewed officials from two  local nongovernmental organizations and from a private organization that  is a Federally Qualified Health Center. In Puerto Rico, we interviewed  officials from a hospital involved in the response; the Puerto Rico Hospital  Association, which represents most of the hospitals in Puerto Rico; and  the Puerto Rico Voluntary Organizations Active in Disaster. We also  received written responses from a local nongovernmental organization  and a national nongovernmental organization that assisted in the  response to Hurricane Maria in Puerto Rico to questions we posed  related to ASPR’s leadership of the response.

We identified the stakeholders we interviewed through referrals from  other stakeholders we had interviewed (e.g., agency officials,  nongovernmental organizations)—an iterative process known as  “snowball sampling.” In total, we interviewed or received written  responses from eight stakeholders. These eight stakeholders represent a  nonprobability sample, and as such, our findings from these interviews  are not generalizable beyond those we interviewed; however, they can  provide insights into the challenges faced by ASPR in the ESF#8  response to Hurricanes Irma and Maria in the U.S. Virgin Islands and to  Hurricane Maria in Puerto Rico. As we examined ASPR’s leadership of  the response, we identified any deficiencies in preparedness or policy  that, if not addressed, could negatively impact future large-scale ESF#8  responses. We assessed ASPR’s leadership of the federal ESF#8  response against the National Response Framework and the Emergency  Support Function #8 – Public Health and Medical Services Annex.

To examine steps ASPR has taken to evaluate its response to Hurricanes  Irma and Maria, we examined ASPR’s after-action report for the 2017  hurricane season and its related improvement plan, as well as other  documentation related to the after-action review process. We also  interviewed ASPR officials to gather information on how the review was  conducted and its status. Further, we interviewed officials from FEMA,  DOD, VA, and the territories to understand the extent of their involvement  in ASPR’s after-action review. We assessed ASPR’s after-action review  steps against Standards for Program Management and Standards for  Internal Control in the Federal Government.

We conducted this performance audit from June 2018 to September 2019  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.

Federal Roles and Responsibilities in Responding to Disasters

Under the National Response Framework, the Department of Homeland  Security is the federal department with primary responsibility for  coordinating disaster response, and within the department, FEMA has  lead responsibility. Due to the massive response needed after Hurricanes  Irma and Maria in the U.S. Virgin Islands and Puerto Rico, FEMA utilized  the National Response Framework to activate all 14 ESFs, including  ESF#8. The National Response Framework designates state, local, tribal,  and territorial agencies as primarily responsible for response activities in  their jurisdictions, including those related to public health and medical  services. However, when effective disaster response is beyond the  capabilities of the state, territorial, or tribal government and affected local  governments, such as was the case for Hurricanes Irma and Maria, those  governments can request federal assistance. The federal response for a  specific ESF is designed to supplement the state, local, tribal, or territorial  resources that respond to a disaster or other emergency. However, due  to the physical destruction of the two hurricanes in the U.S. Virgin Islands  and Puerto Rico, the territorial government agencies that were tasked  with coordinating resources to respond to such disasters were largely  incapacitated. This resulted in an unprecedented federal role in the  response to these disasters.

As the lead agency for an ESF#8 response, ASPR is responsible for  coordinating the ESF#8 response core capabilities outlined in the  National Response Framework. These core capabilities include  assessment of public health and medical needs, patient evacuation,  patient care, the provision of medical equipment and supplies, and public  health communication, among others. ASPR coordinates these core  capabilities through two main roles defined in the National Response  Framework—the coordinator and the primary agency.

As the coordinator, ASPR oversees and coordinates the  preparedness activities for ESF#8 support agencies,  nongovernmental organizations, and the private sector. For example,  ASPR must maintain contact with support agencies through  conference calls, training, and other activities, prior to events; monitor  the ESF’s progress in being able to meet the outlined core  capabilities; as well as coordinate planning and preparedness efforts  with nongovernmental organizations and the private sector.

As the primary agency, ASPR has significant authorities, roles,  resources, and capabilities to fulfill during an ESF#8 response. Its  responsibilities include notifying and requesting assistance from  support agencies and coordinating resources, as well as working with  all types of organizations, such as ESF#8 support agencies, territory  officials, and other stakeholders to maximize the use of all available  resources.

As part of a response, ASPR may activate the National Disaster Medical  System (NDMS)—an interagency partnership among HHS, DOD, VA, and  the Department of Homeland Security to supplement health and medical  systems and response capabilities during a public health emergency.  Under NDMS, ASPR and its partner agencies provide medical response  (by deploying medical personnel teams, for example), evacuate patients,  and provide medical care in NDMS medical facilities when requested by  state, local, tribal, and territorial governments or other federal agencies.  For example, as part of NDMS, DOD and FEMA may provide  transportation to evacuate seriously ill or injured inpatients. DOD and VA  may operate and staff NDMS Federal Coordinating Centers, which are  activated during an emergency to receive, triage, stage, track, and  transport patients affected by a disaster or national emergency to a  participating NDMS medical facility capable of providing the required care  to manage the patient’s condition.

After an ESF#8 response, ASPR evaluates HHS’s disaster response  activities through an after-action review. According to the Department of  Homeland Security’s Homeland Security Exercise and Evaluation  Program guidance, which ASPR follows, this review should include  collecting feedback about the response activities to identify strengths and  areas for improvement, and developing corrective actions to address  identified areas for improvement. This information is then documented  in an after-action report and corrective action improvement plan.

Population Demographics and Hospital Systems in the U.S. Virgin Islands and Puerto Rico

The populations in the U.S. Virgin Islands and Puerto Rico are older than  the general U.S. population. Estimates indicate that the total population in  the U.S. Virgin Islands in 2018 was approximately 107,000 and about 18  percent (or about 19,000 individuals) were age 65 or older. Estimates for  Puerto Rico indicate that the total population in 2018 was approximately  3.3 million and about 20 percent (or about 666,000 individuals) were age  65 or older. In comparison, almost 16 percent of the general population in  the 50 states and the District of Columbia, totaling approximately 329.3  million, were age 65 or older in 2018.

To serve these populations, the U.S. Virgin Islands has two hospitals, one  on St. Thomas and one on St. Croix, each with a capacity of 150 beds.  Puerto Rico has 68 hospitals scattered throughout the island. The  capacity of beds ranges from less than 10 to 515, with a total of almost  10,000 hospital beds to serve the territory.

Hurricanes Irma and Maria and Their Effects on the U.S. Virgin Islands and Puerto Rico

The 2017 Atlantic Hurricane season was one of the most active seasons  in U.S. history, causing widespread damage and destruction to significant  populations in the continental United States and the territories. In  particular, two hurricanes—Irma and Maria—struck in quick succession  and devastated the U.S. Virgin Islands and Puerto Rico.

Hurricane Irma – a category 5 storm passed by the U.S. Virgin  Islands—St. Thomas and St. John—on September 6, and continued  by Puerto Rico. In the U.S. Virgin Islands, the storm caused high  storm surge, flooding, extensive damage to buildings and  infrastructure, and widespread power outages. It became one of the  strongest Atlantic hurricanes on record.

Hurricane Maria – a category 5 storm passed by the U.S. Virgin  Islands—St. Croix—on September 20, and made landfall in Puerto  Rico as a category 4 storm. Hurricane Maria compounded the  damage caused by Hurricane Irma in the U.S. Virgin Islands, and  devastated Puerto Rico. Heavy flooding and high winds led to the  catastrophic damage to Puerto Rico’s power grid, as well as severe  damage to the water, communications, transportation, and health care  infrastructure. The majority of Puerto Rico’s power grid was down for  nearly two months following Hurricane Maria, with outages continuing  through 2018.

Figure 1 depicts the paths of Hurricanes Irma and Maria.

Figure 2 contains photographs of damage sustained in the U.S. Virgin  Islands.

Figure 3 contains photographs of damage sustained in Puerto Rico.

Additional 2017 Hurricanes Requiring an ASPR Response

At the same time ASPR was responding to the catastrophic hurricanes in  the U.S. Virgin Islands and Puerto Rico, the agency was also responding,  or had recently responded, to hurricanes in other areas. Specifically,  ASPR led the ESF#8 response to Hurricane Harvey, a category 4  hurricane that made landfall in Texas on August 25, 2017. Further, in  addition to responding to the effects of Hurricane Irma on the U.S. Virgin  Islands, ASPR was leading the response to that hurricane in Florida.  Also, while ASPR was still responding to Hurricanes Irma and Maria,  Hurricane Nate, a category 1 hurricane, hit Louisiana and Mississippi on  October 7 and 8, 2017, respectively. While not as severe as the prior  hurricanes, Hurricane Nate resulted in wind damage, flooding, and storm  surge, and required a public health and medical services response.  (See figure 4 for a timeline of the 2017 hurricanes requiring ASPR to lead  an ESF#8 response.)

ASPR and Support Agencies Evacuated Patients and Deployed Medical Staff and Facilities to the U.S. Virgin Islands and Puerto Rico

ASPR and support agencies evacuated critical care and dialysis patients  and deployed medical staff and temporary medical facilities as part of the  response to Hurricanes Irma and Maria. These activities centered on  saving lives and preventing human suffering.

Evacuations of Critical Care and Dialysis Patients

During the response to Hurricanes Irma and Maria, ASPR led the NDMS  evacuation of critical care and dialysis patients.

According to ASPR officials, Hurricane Irma damaged critical health  care infrastructure and created a deteriorating situation in St. Thomas  that necessitated life-saving evacuations to Puerto Rico, particularly  as St. Croix’s health care facilities could not support the needs of both  islands. Specifically, after Hurricane Irma damaged the only hospital  on St. Thomas, ASPR prioritized evacuating critical care patients to  Puerto Rico. Once ASPR officials further determined that St. Thomas  did not have the capacity to treat dialysis patients, ASPR also  coordinated the movement of dialysis patients to Puerto Rico. This  was the first time ASPR had coordinated the evacuation of such  patients during an ESF#8 response. ASPR used HHS’s Centers for  Medicare and Medicaid Services’ data to locate dialysis patients on  St. Thomas who were unable to be reached by local authorities for  evacuation.

As the threat of Hurricane Maria making landfall in Puerto Rico  became evident, ASPR began moving U.S. Virgin Islands patients  previously evacuated to Puerto Rico to the continental United States,  according to ASPR and Department of Interior documentation. See  figure 5 for a timeline of patient evacuations conducted through  NDMS from the U.S. Virgin Islands and Puerto Rico after Hurricanes  Irma and Maria.

ASPR worked with other agencies to evacuate NDMS patients.  Specifically, ASPR relied on DOD to provide transportation because HHS  did not have its own transportation capabilities. For example, DOD  provided personnel and transportation to conduct aeromedical  evacuations of patients from the U.S. Virgin Islands to Puerto Rico and  the continental United States. In addition, DOD operated a Federal  Coordinating Center in the continental United States, and VA operated  Federal Coordinating Centers in Puerto Rico and the continental United  States to receive evacuated patients and place them into NDMS medical  facilities. For example, the day after Hurricane Irma passed the U.S.  Virgin Islands, ASPR requested that VA operate the San Juan Federal  Coordinating Center to begin receiving evacuated U.S. Virgin Islands  patients. See figure 6 for a photograph of NDMS evacuation of U.S. Virgin  Islands dialysis patients to the continental United States.

Deployment of Medical Staff and Temporary Facilities

During the response to Hurricanes Irma and Maria, ASPR and some of its  ESF#8 support agencies—DOD and VA—deployed medical staff and  temporary medical facilities to respond to the public health and medical  needs in the U.S. Virgin Islands and Puerto Rico. Using these medical  assets, ASPR and its support agencies served almost 16,000 patients in  Puerto Rico and almost 2,000 patients in the U.S. Virgin Islands over the  course of about four weeks after Hurricane Maria, according to ASPR  reports. Examples of ASPR medical staff and facilities include, but are not  limited to, the following:

Disaster Medical Assistance Teams. ASPR placed Disaster Medical  Assistance Teams in front of the major hospitals in the U.S. Virgin  Islands and Puerto Rico to triage patients and to relieve the hospitals’  emergency departments by treating patients with acute care needs  during the response to Hurricanes Irma and Maria. Disaster Medical  Assistance Teams comprise about 35 medically trained personnel and  equipment. In addition, Disaster Medical Assistance Teams were  sometimes divided into six-person teams—known as Health Medical  Taskforce Teams—that are more agile, according to ASPR officials.  These smaller teams supported response operations in the U.S.  Virgin Islands and Puerto Rico by traveling into hard–to-reach places  to provide acute medical care, stabilize patients, and call for the  transport of patients, when needed. According to ASPR officials,  ASPR deployed a Disaster Medical Assistance Team to Puerto Rico  prior to Hurricane Maria making landfall and then divided it into  smaller teams to provide medical care around San Juan, Puerto Rico.  According to these officials, HHS was one of the few federal agencies  to have operational personnel available immediately post landfall. See  figure 7 for photographs of Disaster Medical Assistance Teams setting  up and providing services in Puerto Rico.

Federal Medical Stations. ASPR placed Federal Medical Stations in  tents in front of hospitals in Puerto Rico after Hurricane Maria made  landfall to assist with relieving the hospitals’ emergency  departments. Federal Medical Stations are to have a 3-day supply of  medical and pharmaceutical resources to sustain up to 250 stable,  primary, or chronic care patients. Because the entire island of  Puerto Rico was affected by Hurricane Maria, ASPR implemented a  “hub and spoke” strategy for the first time—a system to deliver  medical care over affected areas’ population centers—according to  ASPR officials. Under this strategy, ASPR designated San Juan’s  Centro Medico hospital as the “hub” of activity with six “spokes”  delivering care to the island’s population centers, and placed Federal  Medical Stations in tents in front of each hospital, including the  “hub.”

USNS Comfort Deployed to Puerto Rico to  Respond to Hurricane Maria   The USNS Comfort is a seagoing medical  treatment facility that had more than 850  medical and support staff embarked as part of  the public health and medical services  response to Hurricane Maria in Puerto Rico,  according to Department of Defense (DOD)  officials. DOD officials stated that  approximately 2,000 patients in Puerto Rico  were provided care on the USNS Comfort  during the course of its 45-day relief mission  that began in early October 2017.  The USNS Comfort’s primary mission is to  provide an afloat, mobile, medical–surgical  facility to the U.S. military that is flexible,  capable, and uniquely adaptable to support  expeditionary warfare. The ship’s secondary  mission is to provide full hospital services to  support U.S. disaster relief and humanitarian  operations worldwide.

Medical Companies provided trauma, medical, and surgical care to  populations in Puerto Rico after Hurricane Maria. Among other  medical facilities, DOD also provided a Combat Support Hospital to  Puerto Rico 3 weeks following Hurricane Maria—which consisted of  44 beds with emergency medical technicians; an operating room,  laboratory, pharmacy, and X-ray machine; and primary care and  intensive care capabilities. DOD also sent the USNS Comfort—a  hospital ship maintained by the U.S. Navy that served as a mobile,  floating hospital—to help relieve the hospitals in Puerto Rico.

VA medical staff. VA deployed medical personnel through its  Disaster Emergency Medical Personnel System—VA’s main  deployment program for clinical and non-clinical staff to an emergency  or disaster—to assist ASPR with staffing the Federal Medical  Stations. According to VA officials, these personnel worked side by  side with other federal personnel, such as Disaster Medical  Assistance Teams, to provide medical assistance.

Hurricanes Irma and Maria Highlighted Key Deficiencies in ASPR’s Emergency Response Leadership

Our review identified several key deficiencies with ASPR’s leadership of  the federal public health and medical services response to Hurricanes  Irma and Maria in the U.S. Virgin Islands and Puerto Rico that could  adversely affect future large-scale responses unless they are addressed.

Limited ASPR presence in the U.S. Virgin Islands. As the primary  agency, ASPR is responsible for coordinating the ESF#8 response,  including coordinating with support agencies and officials at operations  centers. Further, FEMA’s ESF#8 statement of work for ASPR states that  HHS should provide appropriate personnel at emergency operations  centers near disaster sites to lead an ESF#8 response. HHS officials  maintained that the Department is not required to address all capabilities  in the ESF#8 statement of work, as the actual response provided by HHS  depends on other factors, such as resource availability.

Emergency Operations Center  An emergency operations center is a physical  location where responders, including federal  and state/territory responders, as well as  nongovernmental responders, can meet to  coordinate information and resources to  support incident management (on-scene  operations) during a response.  According to Department of Homeland  Security documentation, decision makers  gather at emergency operations centers to  ensure they receive the most current  information, which allows for improved  communication and decision-making during a  response.

During the initial weeks after the hurricanes, ASPR liaison officers  were not always stationed at the emergency operations centers in St.  Thomas and St. Croix. Instead, the liaisons rotated between the  emergency operations center, hospital, and airport on each island to  manage patient evacuations, or stayed at the hospital, according to  ASPR officials. This led to confusion with regard to the ESF#8  response status on the ground, according to FEMA, DOD, and  territory health officials. For example, FEMA officials stated that when  they needed information on patients’ health needs and evacuation  status, they had to spend time trying to locate an ASPR liaison officer  to obtain it. The FEMA officials then had to relay this information to  DOD, territory health officials, and hospital representatives who were  making numerous requests for this information to FEMA in ASPR’s  absence at the centers. FEMA officials stated that relaying medical  information was outside their areas of expertise as were other  activities they conducted in ASPR’s absence, such as addressing  public health issues at shelters. One FEMA official stated that he had  to read handwritten notes from the hospital that contained patient  information, such as vitals and prescription needs, and provide this  information to other responders. Without a medical background, he  did not know the meaning of a lot of the medical terms used.  Furthermore, these FEMA officials stated that given communication  systems were down on the islands, having a reliable, physical  presence at the emergency operations centers in St. Thomas and St.  Croix became even more critical.

After a few weeks into the response, ASPR liaison officers were  stationed at emergency operations centers, according to ASPR  officials, but the officers generally rotated about every 2 weeks with  limited time to hand off information and were often not from Region II.  This limited ASPR’s leadership of the response and put undue  resource strain on other responders, according to FEMA and territory  health officials. For example, according to FEMA and U.S. Virgin  Islands health officials, the liaison officer would not necessarily  understand the big picture, the tasks to be done, or the players  involved. Thus, FEMA and territory health officials would have to take  time to bring the ASPR liaison officer up to speed on the pressing  public health and medical services issues, and shortly thereafter the  officer would leave to be replaced by someone else, who would also  need to be brought up to speed.

ASPR officials provided two different reasons for the staffing challenges  encountered at the emergency operations centers in the U.S. Virgin  Islands.

First, some ASPR officials cited personnel resource constraints.

Specifically, these officials stated that ASPR personnel had already  been deployed multiple times, given the prior hurricane (Hurricane  Harvey) and concurrent events that ASPR was responding to in  multiple locations. As a result, officials said there was not enough time  to educate rotating officials on issues faced in the U.S. Virgin Islands  and deployments were shorter than ideal.

Second, other ASPR officials stated that a lack of transportation from  Puerto Rico to the U.S. Virgin Islands may have resulted in minimal  overlap of liaison officers. According to these officials, they had to  request such transportation from FEMA, and FEMA did not always  prioritize their needs, since it was also managing transportation needs  from other ESFs. However, FEMA officials contested this statement  and stated there was ample opportunity for ASPR liaison officers to  get to the U.S. Virgin Islands.

In retrospect, ASPR officials acknowledged that staffing emergency  operations centers, as well as other strategic locations is ideal. ASPR  documentation after the response states that the officers’ presence at  emergency operations centers is important because they need to be  working at the operational and tactical levels on the ground. In addition to  staffing emergency operations centers, ASPR officials agreed with  statements from FEMA and DOD officials who told us that the ideal  scenario would be to have at least one other liaison officer (if not more) to  support the lead liaison officer at all strategic locations. The officials noted  that the number of liaison officers may vary depending on the response  needs. In the case of patient evacuations, for example, this would include  having a liaison officer at the airport and one at the hospital, in addition to  the lead at the emergency operations center. In contrast, DOD officials  stated that after Hurricane Irma, one ASPR liaison was on St. Croix trying  to manage all the ESF#8 activities, including patient evacuations and  hospital assessments, which was too much for one person.

In May 2019, ASPR officials told us they have a long-term goal of creating  an incident response team that will comprise 17 full-time response  personnel. If implemented, this strategy may allow ASPR to provide more  liaisons on the ground during a response and address the staffing  deficiency we identified. However, ASPR officials did not provide us with  a draft strategy or a timeline for the creation of such a team. Until ASPR  develops a response personnel strategy to ensure it has sufficient liaison  officers available to consistently lead a response from emergency  operations centers and other strategic locations, the agency risks  repeating the challenge encountered in the U.S. Virgin Islands—notably,  a situation with inadequate liaison officer presence to effectively lead a  response on the ground.

Delay in tracking evacuated patients. Tracking NDMS evacuated  patients and ensuring their care is a critical component of the public  health and medical services response. The ESF#8 Annex of the National  Response Framework states that patients should be tracked from their  point of entry into NDMS.

However, our review found that ASPR did not track patients evacuated  through NDMS from the U.S. Virgin Islands to Puerto Rico immediately  after Hurricane Irma. This occurred because of delays in getting HHS  tracking personnel to the territories, according to VA documentation, as  well as ASPR, DOD, VA, FEMA, and U.S. Virgin Islands Department of  Health officials. Specifically, HHS teams that track patients were not  deployed to the region until about 5 days after patients were already  being evacuated through NDMS. These teams are (1) Joint Patient  Assessment and Tracking System (JPATS) teams, which enter patient  information into JPATS—ASPR’s tracking system—and (2) service  access teams, which track and monitor the status of evacuated patients,  including facilitating movement to home or other final destination after  being discharged from care.

As a result of the delayed deployment of the tracking teams, ASPR  officials did not initially know the locations of some NDMS evacuated  patients in Puerto Rico. For example, once in Puerto Rico, the service  access teams had to drive around the territory looking for evacuees,  according to ASPR officials. ASPR officials explained that there was a  delay in tracking patients after Hurricane Irma because it takes time for  JPATS and service access teams to deploy to a region. ASPR officials  told us that they did not pre-deploy the tracking teams before the  hurricane, because the U.S. Virgin Islands officials did not request  ASPR’s help with patient evacuations until after Hurricane Irma hit.

ASPR officials also stated that at the time of the hurricanes, the agency  had no policy for tracking patients from the start of NDMS evacuations;  however, since the hurricanes, the agency has developed a federal  patient movement framework that may help prevent future delays in  patient tracking. This framework describes the pre-deployment of JPATS  and service access teams, which would allow for tracking to start at the  beginning of NDMS evacuations. ASPR officials told us this is the optimal  solution. However, during an event such as a hurricane, sufficient notice  for pre-deployment is not always possible. One option identified in  ASPR’s federal patient movement framework is for FEMA to track  patients initially and share these data with ASPR and for DOD to provide  patient movement manifests to ASPR so that the data can be manually  entered into JPATS once deployed, which will contain the overall dataset  for patient tracking. By working with DOD and FEMA, ASPR may be able  to consistently track patients from the start of evacuations even when  there is a deployment delay in HHS’s own tracking capabilities.

While ASPR’s development of the framework is an important step forward  to address delays in patient tracking, ASPR has not exercised the  framework with its NDMS partners to ensure it is sufficient and reliable.  For example, given the potential need to manually enter information into  JPATS, there could still be a delay in HHS knowing where patients are  located and being able to inform family members. An exercise of the  framework could help determine if this is indeed a concern that needs to  be addressed. We have previously reported that exercises are a key tool  for testing and evaluating preparedness. ASPR officials told us that  exercising the framework prior to the next hurricane season had been  discussed, but as of May 2019, nothing had been scheduled. Without a  framework that has been exercised with the other agencies involved in  federal patient movement and tracking, ASPR risks delays in patient  tracking when conducting future NDMS patient evacuations.

Final status of one-fourth of evacuated patients not readily available.  The ESF#8 Annex of the National Response Framework states that  NDMS evacuated patients should be tracked to their final disposition.  Further, federal internal controls standards stress the importance of  information controls to ensure quality information is used to achieve  objectives, which includes information that is complete and accurate.

However, we found that of the approximately 800 NDMS patient  evacuations during the response to Hurricanes Irma and Maria, the  agency could not readily provide us with the final status of approximately  200 of these patients. ASPR officials stated they did not have  information indicating the final status of the 200 evacuated patients,  because case workers are not required to report this information to  ASPR. ASPR officials explained that the case workers on the service  access teams deployed during the response are responsible for keeping  track of patients’ final status. However, we found that without conducting  a review of files in which the case workers recorded patients’ final status,  ASPR officials could not determine if the patients were appropriately  discharged and returned back to the U.S. Virgin Islands, left the system  against medical advice, or were otherwise unaccounted for.

Additionally, as of June 2019, ASPR did not provide documentation  indicating the steps the agency takes to ensure the data held by case  workers are accurate. Until ASPR has controls in place to ensure that  data on NDMS evacuated patients are complete and accurate, the  agency cannot ensure it is sufficiently tracking all NDMS evacuated  patients and risks losing track of patients when conducting future patient  evacuation efforts.

Limited focus on chronic and primary care needs in isolated  locations. As the coordinator, ASPR is responsible for ensuring that  appropriate planning and preparedness activities are undertaken. This  includes planning for the care of elderly and chronically ill patients in  isolated areas.

Our review found that at the time of the hurricanes, ASPR Region II’s  response plans for the U.S. Virgin Islands and Puerto Rico—known as  Incident Response Plans—did not account for the need for chronic and  primary care in isolated communities. This type of care was greatly  needed, given that many people, especially the elderly, could not easily  access hospitals, according to officials from ASPR, DOD, the Puerto Rico  Department of Health, and three stakeholders we interviewed. Consistent  with the views of these officials, the HHS Deputy Inspector General  reported that during Hurricane Maria, hundreds of patients across Puerto  Rico sought access to urgent care, primary care, and pharmacy services  at community-based health care centers, known as Federally Qualified  Health Centers, because they could not travel to hospitals for treatment.  Further, we reported in May 2019 and heard from two stakeholders that  because of the widespread power outages and infrastructure damage in  both territories, the chronically ill often did not have access to electricity to  power their medical devices—such as ventilators—and gasoline to run  generators was scarce.

ASPR’s initial response activities—which generally focused on supporting  the hospitals and patients with acute care needs—were based on  response plans with assumptions that did not hold true given the  unprecedented level of destruction in the areas. Specifically, according to  ASPR officials, the agency focused its response planning on managing the surge of patients at hospitals, assuming that individuals would make  their way to hospitals, and projecting that smaller communities could care  for one another until further needs assessments could be conducted. For  example, ASPR Region II and Puerto Rico health officials assumed in  their planning that patients in the harder to reach areas, such as the  mountainous areas, would make their way to the coast where hospital  care was available, according to ASPR officials.

ASPR officials also stated that preparedness planning for an immediate  response is generally focused on managing the surge of patients at  hospitals, with the assumption that after about a week into the response,  assessments would be conducted to determine other needs, such as  chronic care needs. However, ASPR officials told us that in retrospect,  the planning and the assumptions used for planning for the U.S. Virgin  Islands and Puerto Rico were not adequate given the unprecedented  level of destruction in the areas, which affected communications and  transportation. FEMA officials also said that given how difficult it was to  assess the situation in Puerto Rico after Hurricane Maria, having prior  knowledge of the situation on the ground that could affect the response  (such as the general public health and medical needs in the territories  during non-disaster times) was a lesson learned that applies to them, as  well as ASPR.

ASPR has taken steps to better account for the need for chronic and  primary care in isolated communities in future public health and medical  services responses. However, these efforts have not been finalized or  incorporated into ASPR Region II Incident Response Plans for the  territories, which according to a lead HHS Region II official, are internal  agency plans that serve as a playbook for HHS officials during an ESF#8  response in these territories. Specifically, ASPR is working with the  Puerto Rico Department of Health officials to map the locations of health  care facilities in Puerto Rico—such as clinics, Federally Qualified Health  Centers, urgent care centers, and hospitals—including their bed,  generator, communication, and surge capacities. This is the first time all  such information has been brought together, and ASPR continues to work  on this effort as it helps the territory recover, according to agency  documentation. ASPR officials also told us that moving forward they  would like to involve Federally Qualified Health Centers in planning and  response activities, including involving them in the provision of primary  care during responses.

We agree that these are important steps that ASPR can take to address  this deficiency. However, until ASPR Region II Incident Response Plans  for the territories include the provision of chronic and primary care in  isolated communities, there is a risk that disaster survivors will not receive  needed care. For example, this could include the incorporation of  Federally Qualified Health Centers or other local health clinics into these  plans.

Misalignment of support agencies’ capabilities to response needs.  As the coordinator, ASPR is responsible for ensuring that appropriate  planning and preparedness activities are undertaken, including monitoring  the progress in meeting the ESF#8 core capabilities. Further, FEMA  guidance issued in June 2015 states that each ESF coordinator should  maintain a capabilities inventory for the ESF.

However, our review found that ASPR did not have a sufficient  understanding of ESF#8 support agencies’ capabilities prior to the  hurricanes. Consequently, ASPR’s resource needs for the response in  the U.S. Virgin Islands and Puerto Rico were not always aligned with the  resources its support agencies—DOD, VA, and FEMA—could provide.  According to ASPR documentation and DOD officials, this resulted in  some deployed resources not being properly and efficiently utilized.

As an example of the misalignment of resources, DOD officials told us  that, through FEMA, ASPR requested that DOD provide stand-alone  medical assistance teams (i.e., teams of medical personnel and  equipment, similar to ASPR’s Disaster Medical Assistance Teams) to  deliver medical care to the hurricane survivors in the U.S. Virgin Islands  and Puerto Rico. However, since DOD does not have stand-alone teams,  it deployed Area Support Medical Companies, which included facilities,  equipment, and supply packages. These teams are equipped to serve the  military population—those approximately 18-60 years of age, wounded,  and requiring trauma and medical-surgical care. However, trauma and  medical surgical care was not the primary need in the islands, which, in  general, have an older population with chronic and primary care needs.

ASPR documentation also shows that ASPR had trouble defining how  FEMA and DOD assets fit into the overarching ESF#8 response. For  example, ASPR documentation states that it took the agency nearly a  week to fully realize that the two Area Support Medical Companies  provided by DOD were not equivalent to the five stand-alone medical  assistance teams that HHS had requested. According to DOD officials,  the misalignment of resources during the response was troublesome as  the Department’s involvement in the ESF#8 response activities affected  patient care for military health beneficiaries and potentially increased  overseas contingency response risks for the Department. In another  example, during the response, there were conflicting expectations about  VA personnel’s role in supporting the Federal Medical Stations, with VA  responders thinking they would run shelter operations and ASPR  believing the VA staff would support medical operations, according to  ASPR documentation.

According to ASPR officials, the agency had never anticipated needing— and therefore did not plan for—certain ESF#8 agency support, such as  teams similar to ASPR’s Disaster Medical Assistance Teams. ASPR’s  role in a response has traditionally been to support states or territories;  however, because of the catastrophic nature of the hurricanes, ASPR  effectively led the territories in the response as opposed to playing a  supporting role. ASPR’s response system was not designed to handle  that large of a role, according to officials.

Since the hurricanes, ASPR has taken steps to understand the resources  available from its support agencies, but ASPR officials agreed that it is an  activity that the agency needs to continue to undertake. Specifically,  ASPR officials stated that the agency is currently working with its NDMS  partners (FEMA, DOD, and VA) to develop memorandums of agreement  that outline the roles and responsibilities of each organization; however,  the discussions are in the preliminary stages as ASPR continues to  collaborate with each organization to understand their resource gaps and  capabilities. Continuing to understand each ESF#8 support agency’s  potential capabilities and its limitations—knowing that the actual capacity  of these capabilities may fluctuate—is important, as evidenced by the  misalignment that occurred during the response. Until ASPR can better  identify the capabilities and limitations of support agencies to meet ESF#8  core capabilities, ASPR cannot, as the coordinator, determine whether  the ESF is prepared for future disasters.

Reliance on DOD support. As the coordinator, ASPR is responsible for  ensuring that appropriate planning and preparedness activities are  undertaken. This includes planning for a scenario in which DOD  assistance is unavailable. We have previously reported that DOD  provided much of the ESF#8 support during the initial response to  Hurricanes Irma and Maria, which may not always be available in future  responses. DOD’s support included providing the core capabilities of  patient care (through the provision of Area Support Medical Companies,  among other medical facilities) and patient evacuations (through the  provision of personnel and transportation to conduct aeromedical  evacuations), as mentioned above.

We found that ASPR does not have a response strategy that will account  for the core capabilities needed to be filled by itself or other support  agencies in a large or long-term ESF#8 response if DOD were unable to  assist. For example, DOD’s 2017 hurricane after-action report included  reliance on DOD as a concern and recommended that HHS and FEMA  establish contracts with the commercial sector to ensure the federal  government has other options available for larger ESF#8 responses  should DOD not have the needed capability or available capacity.  Similarly, in September 2018, we reported that ESF lead agencies’  (including ASPR for ESF#8) dependence on DOD capabilities was a  challenge for DOD during the response to Hurricanes Irma and Maria. We  reported that the increased reliance may create vulnerability, if in the  future, DOD capabilities are needed to conduct its primary mission—to  defend the nation from threats—at the same time its support is needed for  a domestic disaster response.

ASPR told us that it does not have a contingency plan for a response in  DOD’s absence, because for large-scale events, such as Hurricanes Irma  and Maria, ASPR has to rely on DOD, given ASPR’s own resource  constraints. ASPR officials stated that, in general, ASPR’s resource  response capacity—personnel and supplies—can support a response to  two simultaneous events that occur in different areas in the Continental  United States for 30 days. Beyond that, ASPR has to rely on other  agencies, including DOD, which occurred with Hurricanes Irma and  Maria.

However, ASPR officials did state that the agency has recently taken  some steps to reduce its reliance on DOD. Specifically, in September  2018, ASPR entered into a contract with a private company to provide  medical personnel teams similar to Disaster Medical Assistance Teams  that can be utilized to supplement ASPR response personnel, especially if  DOD resources are not available. Similarly, to assist with future patient  evacuations, in October 2018, the agency entered into contracts with  private companies for commercial air ambulance transport. In addition,  ASPR officials told us that through ASPR’s participation in the Whole of  Government Logistics Council, the agency has begun to further discuss  air transport options during major disasters with other agencies including  FEMA, DOD, and VA. However, ASPR officials also stated there is a  need to hold discussions with all agencies involved in the ESFs to  prioritize and coordinate air transportation during a response in the event  that DOD is not available.

While these are important steps to potentially minimize reliance on DOD,  ASPR’s own capacity constraints make it all the more important for ASPR  to a develop response strategy that includes other support agencies in  the event that DOD support is unavailable. For example, such a strategy  could involve conducting an exercise to simulate a large-scale ESF#8  response without DOD capabilities. Until ASPR develops a strategy  demonstrating how ESF#8 core capabilities can be provided through HHS  and its support agencies without DOD’s assistance, it risks being  unprepared to respond to a large-scale disaster or multiple disasters if  they occur when DOD’s capabilities are limited due to other events, such  as military missions.

While ASPR Has Completed a Draft After-Action Report to Evaluate Its Response, It is Missing Key Perspectives

ASPR completed a draft after-action report in February 2018 after several  months of collecting feedback from HHS staff on the strengths and areas  for improvement in the agency’s 2017 ESF#8 response activities;  however, the draft is missing the perspectives of key parties involved in  the response. Not collecting the perspectives of key parties involved in  the response is inconsistent with federal standards for information and  communication, which state that management needs access to relevant  information from external parties to help achieve objectives and address  related risks. Further, the Standard for Program Management states  that program managers should actively engage key stakeholders  throughout the life cycle of a program, which would include any evaluation  activities.

Specifically, when collecting feedback, ASPR did not reach out directly to  support agencies, territorial governments in the U.S. Virgin Islands and  Puerto Rico, or other stakeholders intimately involved in the response.  Instead, ASPR gathered observations through facilitated discussions, or  “hotwashes,” with HHS personnel stationed at key response sites in  headquarters and the field, such as personnel stationed at the HHS Secretary’s Operations Center and those stationed at medical sites in  Puerto Rico. In addition, ASPR distributed an electronic feedback link to  all personnel involved in the HHS ESF#8 response, both in the field and  headquarters.

ASPR officials stated they did not obtain feedback directly from outside  parties, such as support agencies or territorial governments, during the  after-action review because the review was focused on internal aspects of  the HHS response. Instead, the officials said that FEMA—as the overall  lead for the federal response—typically writes the overall after-action  report for the whole federal government, and those perspectives would be  captured there. However, FEMA’s after-action report was focused only on  its response activities for the 2017 hurricanes and did not include any  strengths or areas for improvement related to ESF#8.

Because ASPR did not obtain feedback from its ESF#8 support agencies  and other partners, its draft after-action report dated February 2018 has  key gaps in its assessment. For example, three of the deficiencies we  identified based on our review of documentation and interviews with  agency and territory officials—the delay in tracking evacuated patients,  the final status of some evacuated patients not readily available, and the  reliance on DOD support—were not included in ASPR’s draft after-action  report. This indicates that key perspectives, and related lessons learned,  were missing from ASPR’s after-action review. Similarly, FEMA officials  said that during the course of soliciting feedback on its own response  actions, FEMA’s provider of NDMS medical evacuation transportation for  Hurricanes Irma and Maria said that if ASPR had reached out, it would  have identified challenges with the NDMS patient evacuations conducted.  In particular, the provider told FEMA that patients were evacuated to an  airport in the continental United States with limited hours of availability,  and if patients had to be evacuated outside of those hours, they were  sent to other airports with inadequate medical care, so the patients  needed to be transported again as a result.

Without an after-action report that includes the perspectives of all key  parties—including ESF#8 support agencies—ASPR management is likely  to lack the necessary information to comprehensively identify all strengths  and areas for improvement of its ESF#8 response.

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, transportation, and  health care infrastructure in the territories. ASPR and its support  agencies, such as DOD, undertook numerous actions to address the  public health and medical needs in the territories—including evacuating  critical care and dialysis patients from the U.S. Virgin Islands and Puerto  Rico.

Nevertheless, key deficiencies with ASPR’s leadership of the response  resulted in confusion and resource strain among responders from support  agencies and territory health departments at emergency operations  centers in the U.S. Virgin Islands. The deficiencies also resulted in  service access teams having to search for evacuated patients, ASPR’s  inability to readily and reliably identify the final status of all evacuated  patients, and disaster survivors in isolated areas potentially not receiving  needed health care. ASPR’s leadership also led to an inefficient use of  federal resources. Many of the deficiencies were a function of ASPR  policy and its preparedness planning, and as such, they could be  repeated unless ASPR addresses them. Additionally, the agency remains  unprepared to respond to future large-scale disasters if DOD is  unavailable. Further, the likelihood that deficiencies will recur in future  responses increases, because ASPR did not include feedback from the  support agencies involved in the response in its after-action report.

We are making the following seven recommendations to the Assistant  Secretary for Preparedness and Response:  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 ESF#8 response and another  liaison, if not more, is at strategic location(s) in the area.  (Recommendation 1)

As ASPR finalizes its federal patient movement framework, the agency  should exercise the framework with its NDMS partners to ensure that  patients evacuated through NDMS will be consistently tracked from the  start of their evacuation. (Recommendation 2)

ASPR should put controls in place to ensure data on all NDMS evacuated  patients are complete and accurate. (Recommendation 3)

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)

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)

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)

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)

We provided a draft of this report for advance review and comment to  HHS, DOD, the Department of Homeland Security, VA, and the  governments of the U.S. Virgin Islands and Puerto Rico. HHS and VA  provided written comments, which we have reprinted in appendixes I and  II, respectively. HHS concurred with five of our seven recommendations  and stated that it had, or was in the process of, taking action. While we  made no recommendations to VA, in its comments VA stated that it looks  forward with working with HHS on matters we have presented in this  report. HHS and DOD provided technical comments, which we  incorporated as appropriate. U.S. Virgin Islands and Puerto Rican  government officials stated they had no comments on the draft report.

HHS did not concur with a recommendation in the draft report directing  ASPR to develop and finalize ESF#8 response plans for the territories  that include strategies for providing chronic and primary care in isolated  communities. In its comments, 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. We modified the  language in our report and our recommendation to clarify we are referring  to ASPR Region II’s Incident Response Plans for the U.S. Virgin Islands  and Puerto Rico. According to a lead ASPR Region II official, these plans  are internal agency plans that serve as a playbook for HHS officials  during an ESF#8 response in these territories. However, as we reported,  these plans do not account for the provision of chronic and primary care  in isolated communities. Accordingly, we believe our recommendation is  warranted.

HHS also did not concur with a recommendation in the draft report that  ASPR work with support agencies to develop an inventory to identify the  capabilities and limitations of support agencies to meet ESF#8 core  capabilities. According to HHS, such an inventory will be out of date  immediately after development due to world events and changes in  investments, technologies, and priorities. Instead, HHS proposed the  continued use of interagency liaison officers at the HHS emergency  operations center, as they can provide real-time updates on available  resources during a response. We agree that HHS should continue this  practice in future responses. However, as is evidenced by the  misalignment that we identify in our report, this action was not adequate  during the response to Hurricanes Irma and Maria in the U.S. Virgin  Islands and Puerto Rico. Further, as we reported, ASPR officials  acknowledged that more needs to be done to better understand the  resources available from its support agencies. To clarify the intent of our  recommendation—that is, that ASPR take steps to ensure it has a  sufficient understanding of each ESF#8 support agency’s potential  capabilities and its limitations—we modified language in our report and  the recommendation. Specifically, we modified our recommendation to  direct ASPR to include information on the capabilities of these agencies  as it works to develop and finalize memorandums of agreement with  support agencies. The memorandums of agreement that ASPR is  beginning to draft with support agencies provide an opportunity to begin  to address this issue. As we have reported, taking such action is needed  to help ensure that future ESF#8 responses are more efficiently and  effectively coordinated.

We are sending copies of this report to the appropriate congressional  committees, the Secretaries of the Health and Human Services, Defense,  Homeland Security, Veterans Affairs, and Interior, and other interested  parties. In addition, the report is available at no charge on the GAO  website at http://www.gao.gov.

If you or your staff have any questions about this report, please contact  me at (202) 512-7114 or DeniganMacauleyM@gao.gov. Contact points  for our Offices of Congressional Relations and Public Affairs may be  found on the last page of this report. GAO staff who made key  contributions to this report are listed in appendix III.

Appendix I: Comments from the Department of Health and Human Services

Appendix II: Comments from the Department of Veterans Affairs

Mary Denigan-Macauley, (202) 512-7114 or  DeniganMacauleyM@gao.gov.

In addition to the contact named above, Kelly DeMots (Assistant  Director), Deirdre Gleeson Brown (Analyst-in-Charge), Kenisha Cantrell,  Justin Cubilo, and Rebecca Hendrickson made key contributions to this  report. Also contributing were Sam Amrhein, Kaitlin Farquharson, and  Vikki Porter.

Disaster Response: FEMA and the American Red Cross Need to Ensure  Key Mass Care Organizations are Included in Coordination and Planning.  GAO-19-526. Washington, D.C.: September 19, 2019.

Disaster Response: Federal Assistance and Selected States and Territory  Efforts to Identify Deaths from 2017 Hurricanes. GAO-19-486.  Washington, D.C.: September 13, 2019.

Disaster Assistance: FEMA Action Needed to Better Support Individuals  Who Are Older or Have Disabilities. GAO-19-318. Washington, D.C.: May  14, 2019.  2017 Disaster Contracting: Actions Needed to Improve the Use of Post- Disaster Contracts to Support Response and Recovery. GAO-19-281.  Washington, D.C.: April 24, 2019.  2017 Hurricane Season: Federal Support for Electricity Grid Restoration  in the U.S. Virgin Islands and Puerto Rico. GAO-19-296. Washington,  D.C.: April 18, 2019.

Disaster Recovery: Better Monitoring of Block Grant Funds is Needed.  GAO-19-232. Washington, D.C.: March 25, 2019.

Puerto Rico Hurricanes: Status of FEMA Funding, Oversight, and  Recovery Challenges. GAO-19-256. Washington, D.C.: March 14, 2019.

U.S. Virgin Islands Recovery: Status of FEMA Public Assistance Funding  and Implementation. GAO-19-253. Washington, D.C.: February 25, 2019.  2017 Disaster Contracting: Action Needed to Better Ensure More  Effective Use and Management of Advance Contracts. GAO-19-93.  Washington, D.C.: December 6, 2018.

Homeland Security Grant Program: Additional Actions Could Further  Enhance FEMA’s Risk-Based Grant Assessment Model. GAO-18-354.  Washington, D.C.: September 6, 2018.  2017 Hurricanes and Wildfires: Initial Observations on the Federal  Response and Key Recovery Challenges. GAO-18-472. Washington,  D.C.: September 4, 2018.

Federal Disaster Assistance: Individual Assistance Requests Often  Granted but FEMA Could Better Document Factors Considered.  GAO-18-366. Washington, D.C.: May 31, 2018.  2017 Disaster Contracting: Observations on Federal Contracting for  Response and Recovery Efforts. GAO-18-335. Washington, D.C.:  February 28, 2018.

Disaster Assistance: Opportunities to Enhance Implementation of the  Redesigned Public Assistance Grant Program. GAO-18-30. Washington,  D.C.: November 8, 2017.

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.