Text: S.Hrg. 115-379 — DISASTER PREPAREDNESS AND RESPONSE: THE SPECIAL NEEDS OF OLDER AMERICANS
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[Senate Hearing 115-379]
[From the U.S. Government Publishing Office]
S. Hrg. 115-379
DISASTER PREPAREDNESS AND RESPONSE: THE SPECIAL NEEDS OF OLDER
SPECIAL COMMITTEE ON AGING
UNITED STATES SENATE
ONE HUNDRED FIFTEENTH CONGRESS
SEPTEMBER 20, 2017
Serial No. 115-9
Printed for the use of the Special Committee on Aging
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
U.S. GOVERNMENT PUBLISHING OFFICE
30-022 PDF WASHINGTON : 2018
SPECIAL COMMITTEE ON AGING
SUSAN M. COLLINS, Maine, Chairman
ORRIN G. HATCH, Utah ROBERT P. CASEY, JR., Pennsylvania
JEFF FLAKE, Arizona BILL NELSON, Florida
TIM SCOTT, South Carolina SHELDON WHITEHOUSE, Rhode Island
THOM TILLIS, North Carolina KIRSTEN E. GILLIBRAND, New York
BOB CORKER, Tennessee RICHARD BLUMENTHAL, Connecticut
RICHARD BURR, North Carolina JOE DONNELLY, Indiana
MARCO RUBIO, Florida ELIZABETH WARREN, Massachusetts
DEB FISCHER, Nebraska CATHERINE CORTEZ MASTO, Nevada
Kevin Kelley, Majority Staff Director
Kate Mevis, Minority Staff Director
Opening Statement of Senator Susan M. Collins, Chairman.......... 1
Statement of Senator Robert P. Casey, Jr., Ranking Member........ 3
Statement of Senator Thom Tillis................................. 5
PANEL OF WITNESSES
Karen B. DeSalvo, M.D., Former Health Commissioner, City of New
Orleans, New Orleans, Louisiana................................ 6
Kathryn Hyer, Ph.D., Professor and Director, Florida Policy
Exchange Center on Aging, School of Aging Studies, University
of South Florida, Tampa, Florida............................... 9
Paul Timmons, President, Portlight Inclusive Disaster Strategies,
Inc., Charleston, South Carolina............................... 11
Jay Delaney, Fire Chief and Emergency Management Coordinator,
City of Wilkes-Barre, Wilkes-Barre, Pennsylvania............... 12
Prepared Witness Statements and Questions for the Record
Karen B. DeSalvo, M.D., Former Health Commissioner, City of New
Orleans, New Orleans, Louisiana................................ 30
Questions submitted for Karen B. DeSalvo..................... 33
Kathryn Hyer, Ph.D., Professor and Director, Florida Policy
Exchange Center on Aging, School of Aging Studies, University
of South Florida, Tampa, Florida............................... 36
Questions submitted for Kathryn Hyer......................... 38
Paul Timmons, President, Portlight Inclusive Disaster Strategies,
Inc., Charleston, South Carolina............................... 42
Questions submitted for Paul Timmons......................... 45
Jay Delaney, Fire Chief and Emergency Management Coordinator,
City of Wilkes-Barre, Wilkes-Barre, Pennsylvania............... 47
Additional Statements for the Record
Senator Marco Rubio, Statement for the Record.................... 50
Katie Smith Sloan, President and CEO, LeadingAge................. 50
James R. Balda, President and CEO, Argentum...................... 52
Teresa Osborne, Pennsylvania Secretary of Aging, and Rick Flinn,
Director, Pennsylvania Emergency Management Agency............. 56
DISASTER PREPAREDNESS AND RESPONSE: THE SPECIAL NEEDS OF OLDER
WEDNESDAY, SEPTEMBER 20, 2017
Special Committee on Aging,
The Committee met, pursuant to notice, at 9:06 a.m., in
Room SD-562, Dirksen Senate Office Building, Hon. Susan Collins
(Chairman of the Committee) presiding.
Present: Senators Collins, Tillis, Fischer, Casey,
Gillibrand, Donnelly, and Cortez Masto.
OPENING STATEMENT OF SENATOR SUSAN M. COLLINS, CHAIRMAN
The Chairman. The Committee will come to order.
Good morning. Recently, Hurricanes Harvey and Irma left a
path of destruction along the gulf coast of Texas, across
Florida, and throughout the Caribbean. Homes, businesses, and
entire communities were destroyed and lives were lost.
Days after Irma, we learned the tragic news that eight
seniors, ranging in age from 71 to 99, died in a Florida
nursing home that lacked air conditioning because the power had
been knocked out. One press account described the facility as
``a death trap'' because the elderly are particularly
susceptible to heat-related illnesses. Last month, this photo
of residents of an assisted living facility in Texas who were
trapped in waist-deep water went viral.
As these recent disasters make clear, older Americans are
particularly vulnerable before, during, and even after a storm.
In fact, when Hurricane Katrina slammed into the gulf coast 12
years ago, more than half of those who died were seniors.
As the then Chair of the Senate Homeland Security
Committee, along with Senator Joe Lieberman of Connecticut, I
led a bipartisan investigation into the response to Hurricane
Katrina at the federal, state, and local levels. Our
investigation, which resulted in this extensive, some would say
weighty report, revealed many weaknesses in our Nation's
emergency response system, and although I doubt very many
people read the whole report, it does have an excellent summary
that I was just discussing with the chief. And it was evident
to me in rereading it that we have learned many of the lessons
of Katrina, but we still have a long ways to go.
One of the weaknesses in our Nation's emergency response
system included the failure on the part of all levels of
government to plan and provide for timely and effective
evaluation of our most vulnerable seniors. Since then, we have
expanded our efforts to improve emergency preparedness and
response across the entire country, and we have emphasized the
protection of the most vulnerable.
Meanwhile, Mother Nature continues to unleash her fury.
Today, even as we meet, yet another hurricane, Maria, is
battering a region still struggling to recover, and it is
expected to hit Puerto Rico particularly hard.
This morning, we will discuss how our federal, state, and
local emergency response efforts have been critical in limiting
the scope of these recent tragedies, and we will identify where
more work is still needed.
On the positive side, improvements in emergency response
efforts at the Centers for Medicare & Medicaid Services have
helped to identify those seniors who require relocation in
order to maintain their dialysis. I was talking with the head
of CMS just yesterday about this, and she said one of the
problems was that the demand was so great that people were not
able to have complete dialysis. They were hooked up to the
machines for 2 hours when they needed a far longer period of
time, but the demand was such that they were just trying to
In addition, local emergency response teams implemented
strategies to identify those most in need and provided
designated shelters that offered necessary medical care and
support. But that, tragically, was not always the case. The
lack of electrical power apparently contributed to the death of
those seniors in the nursing home and to the worsening health
condition of others, suggesting a very troubling lack of
preparedness in some health care centers.
While we have made many strides since Hurricane Katrina
twelve years ago, we must ask ourselves: Can we better protect
the most vulnerable members of our communities? What gaps exist
that could jeopardize lives in the next catastrophe, whether it
is a storm, an earthquake, or some other unanticipated event?
We should not have to wait for the next Irene, Sandy, Harvey,
Irma, or unnamed disaster to strike.
Today we will discuss concrete solutions to protect and
stabilize vulnerable seniors from maintaining necessary
resources and connections during emergencies to relocating and
returning to safe and secure homes during the recovery period.
We will consider the challenges of making the correct choices
of whether it is better to shelter people in place or evacuate
and relocate. And as I have looked more into this issue, I have
learned that that is often a very difficult decision to make,
particularly if you are dealing with people with some sort of
Just one day after Hurricane Irma slammed much of Florida,
a CNN reporter waded about a mile in waist-deep water,
contaminated with oil and garbage, to knock on the door of a
mobile home in Bonita Springs. He had been told that an elderly
couple lived inside and that they did not heed the warnings of
local and state officials to leave prior to the storm. Inside
this mobile home, which was now surrounded by water, lived an
88 year-old woman and her 93 year-old husband who suffered from
Parkinson's disease and diabetes. When the reporter asked the
woman why they did not evacuate, she simply replied: ``We have
everything we need here. We have his medications. It is just
Now, I am very grateful that this couple was found safe,
but to me this story illustrates how we must expand our efforts
to protect vulnerable seniors, not only those who are living in
facilities such as assisted living or long-term care
facilities, but instead are living in their own homes. For many
of those seniors, evacuation is not as easy as packing a bag
and jumping into a car. They may not be able to drive, for
example. Some of these homebound older adults are alone and
frail. They may suffer from diseases. And many of them have
lived in their homes for so long that they just do not want to
leave it behind and are fearful of what will happen if they
Let me conclude by offering my condolences to all those who
experienced losses as a result of these violent hurricanes. My
heart goes out to all of those who are suffering and now face
the considerable challenges in the weeks and months ahead.
I also want to extend my gratitude to the first responders,
including the volunteers, such as a medical team from Maine and
everyone who has reached out to help a neighbor in need, even
as in so many cases they, too, are dealing with the devastation
caused by these terrible storms. While we can and must continue
to improve our emergency response so that the tragic deaths in
Florida's nursing homes do not happen in the future, we should
not overlook the heroic actions of so many.
I want to thank our witnesses for being with us today, and
I am delighted to now recognize the Ranking Member, Senator
OPENING STATEMENT OF SENATOR ROBERT P. CASEY, JR., RANKING
Senator Casey. Chairman Collins, thank you very much for
having this very important hearing, especially at this time.
I join the Chairman in thanking the work of those who have
done emergency response tasks over many, many days now. The
countless volunteers who have helped them throughout these many
days of challenge, we are grateful for that work, and we join
in thanking them for doing that great work.
Together they have worked endless hours over these last
several weeks to save the lives of people in Texas, in Florida,
the U.S. Virgin Islands, and now, of course, folks in Puerto
Rico are facing a difficult number of days ahead; and we are
thinking of them and praying for them at this time. To say that
these actions have been heroic is an understatement. There is
no way to adequately describe that kind of commitment, that
kind of heroism.
But, unfortunately, today we are here because we know that,
despite great efforts by a lot of good people across the
country, older Americans and individuals with disabilities face
extraordinary challenges in a disaster. And, again, that is an
understatement. So many of us were both outraged and enraged
when we saw what happened in Florida, that people died, seniors
died in the midst of this crisis. We are also heartbroken for
the loss of life and also the loss that those families
suffered. In this case it was apparently something as simple as
a lack of air conditioning--something that many of us take for
granted just even on a day like today in this building. It is
hard to comprehend the sadness that will engulf those families
and those communities. So that is one of many challenges we
will speak to today.
Just yesterday, Senator Nelson, who has done great work in
his home State of Florida dealing with these issues, said the
following, he said: ``One life lost is one too many.''
I am proud--and I know that Chairman Collins as well is
proud--that we have joined him in introducing legislation that
would do the following: It would require the Secretary of
Health and Human Services to establish a national advisory
committee on seniors and disasters. A 15-member panel would be
appointed by the Secretary of HHS and made up of federal and
local agency officials as well as non-federal health care
professionals with expertise in disaster response. It is a good
bill. It is bipartisan. We should pass it. Both Senator Nelson
and Senator Rubio have introduced it. So that is one thing that
we can do together to better plan for and respond to these
challenges in the future.
But like all Americans, and I think every American was
stunned by the viral photo that the Chairman just showed of one
nursing home and the water that was rising around those
seniors, in this case in an assisted living facility in Houston
where they were sitting in waist-deep water waiting to be
These are folks who, indeed, to say they are our greatest
generation does not adequately capture it. These are folks who
fought our wars; they worked in our factories; they built the
middle class; they gave us the kind of life that we take for
granted sometimes. They have sacrificed so much, and they have
lived lives of quiet dignity. We have a sacred obligation to
them to make sure those scenes that were depicted in that
photograph and that happened in Florida never happen again.
Just as the Chairman said, all the good lessons that were
learned in the aftermath of Katrina, we have to implement
better practices, best practices to make sure that we learn
from these recent disasters as well. So we need to ensure that
we are doing everything possible to learn from these tragedies,
and we also have to make sure that we are focused, on a day
like today, on better policy. And that is why we gather today
with such a great panel of witnesses.
These witnesses bring not just experiences from the recent
past, but in many cases from years of experience, from
Hurricane Katrina to Hurricane Harvey. They have faced the
double whammy, so to speak, of Hurricanes Lee and Irene back in
2011, as well as the four hurricanes in 6 weeks that ravaged
Florida in the year 2004.
We have learned--and they have learned even more--from each
of these experiences. So we hear from our witnesses, incident
management infrastructure is more robust in some important
areas like hospitals. That is good news, That means we have
learned lessons to implement those changes. Coordination
efforts in advance of storms have been improved, and there are
more comprehensive emergency response requirements being
implemented for nursing homes so that seniors will be better
But we have a long way to go to make sure that we get this
right. Older citizens should not suffer for days and then die
in the unbearable heat. No person with a disability should have
trouble following evacuation orders because of inaccessible
transportation or shelters. And it should go without saying no
senior should fear drowning in their own home, no matter where
Our witnesses here today will explain how we can do better,
because we must do better. We have a sacred obligation to do
I want to thank the witnesses for bringing their
experiences, their expertise, and their passion to these
issues. And I want to thank Chairman Collins for gathering us
on this day.
The Chairman. Thank you very much, Senator Casey.
I am delighted that we have Senator Tillis, Senator
Fischer, and Senator Cortez Masto here with us today, and I
very much appreciate their participation. I know that Senator
Tillis has to get off to the Judiciary Committee, and so I
would like to offer him the opportunity for any comments he
would like to make.
OPENING STATEMENT OF SENATOR THOM TILLIS
Senator Tillis. Thank you, Madam Chair. I do have to chair
the Judiciary Committee, so once I get there, I will not be
able to come back. But I wanted to thank you all for being
here. The building is a little empty today because we adjourned
last night, but you see the focus that these members have to be
here, and thank you all for being here.
You know, I am glad that we framed this as really a
response to disaster. We are going to immediately leap to the
disaster that right now is occurring in Puerto Rico with Maria
making landfall with 175 mile per-hour sustained winds. We can
talk about the recent storms Harvey and Irma, but I could talk
about an enormous impact in North Carolina called Matthew a
year ago on October 8th. And I have a personal story to tell
there because our office, our staff had to help a senior who
had gotten lost in the process, who had left her home, as she
should have. We had almost 20 inches of rainfall in about a 24-
hour period that was devastating to the community, and then the
river rises afterward were even worse, so much so that when
they would go to one shelter, that shelter got closed down
because the water threatened those shelters.
And so it really raised a question, Mr. Timmons--I am going
to submit some questions for the record for all of you to
potentially respond to, but it raises a question about how well
we track evacuees through the life cycle. And I think that life
cycle needs to go before the disaster ever occurs and then
until there is a resolution that makes us feel like that senior
is safe and secure.
I think one of the reasons that we have a challenge with
evacuating seniors is they just have a fear of the unknown. And
if we did a better job of communicating what this would look
like earlier, where they are likely to go, and how we are going
to be stewards of them over the course of the process, then I
think that many who feel like the safest thing to do is to
shelter in place will be replaced with a sense of comfort that
they are going to be taken care of through the process, up to
and including getting them back into their home and living
independently again or living in a facility where they have
been taken care of.
So that life cycle, where it needs to start, how do we
better educate, how do we better link--what we ended up doing
in our office is gluing together--and I think it can be
instructive for things that we need to do differently. But,
fortunately, our Governor, our emergency management folks in
North Carolina helped us find this lady, get her medications,
which were desperately needed, and get her connected to her
family. So that sort of life cycle of disaster that starts
before the disaster ever occurs, until we know that that senior
is safe and sound, is something that I think would be very
helpful and instructive to us to see how we can actually work
at the federal, state, and local level to make that happen.
Thank you all for being here, and thank you for being
focused on helping us come up with a solution. And, again,
Madam Chair, thank you for your work on this subject.
The Chairman. Thank you very much, Senator Tillis.
I am now going to introduce our excellent panel of
First is Dr. Karen DeSalvo. Dr. DeSalvo is a physician and
public health expert. She served as health commissioner in New
Orleans, where she worked hard to restore health care to areas
of the city devastated by Hurricane Katrina. She has also
served as the former Assistant Secretary for Health at the U.S.
Department of Health and Human Services.
Next we will hear from Dr. Kathy Hyer. Dr. Hyer is director
of the Florida Policy Exchange Center on Aging at the
University of South Florida. Dr. Hyer has researched and
written extensively about vulnerable older Americans and the
structure of the emergency response systems. I want to
particularly thank you, Dr. Hyer, for being here today even as
the long recovery process in Florida continues.
We will also hear from Paul Timmons. Mr. Timmons is
president of Portlight Inclusive Disaster Strategies in
Charleston, South Carolina. Despite that mouthful of an
organization's name, he is a leader in the field of disaster
preparedness and response for people who are aging and those
Finally, I am going to turn to our Ranking Member to
introduce our witness from Pennsylvania.
Senator Casey. Thanks very much. I am pleased to introduce
Jay Delaney, who is fire chief and emergency management
coordinator for the city of Wilkes-Barre, Pennsylvania. Chief
Delaney led the response efforts when it became clear that
Hurricanes Irene and Lee could cause the Susquehanna River, the
16th largest river in the United States, to overwhelm our
levees in the community of Wilkes-Barre, Pennsylvania. With the
clock ticking and the waters rising, Chief Delaney safely
evacuated 15,000 people in just 10 hours, including our
hospitals and nursing homes. I look forward to the chief's
testimony. Thanks, Chief.
The Chairman. Thank you very much, Senator.
We will start with Dr. DeSalvo.
STATEMENT OF KAREN B. DeSALVO, M.D., FORMER HEALTH
COMMISSIONER, CITY OF NEW ORLEANS, NEW ORLEANS, LOUISIANA
Dr. DeSalvo. Thank you, and good morning, Chairman Collins
and Ranking Member Casey and distinguished members of the
Committee. Thank you all for making time in a very busy agenda
of the Senate to talk about this priority issue of seeing that
we have an opportunity to better support and protect older
Americans in times of disaster and every day. I am Karen
DeSalvo. I am a physician, and I was formerly the health
commissioner in New Orleans--not during the time of Katrina but
subsequently, and I certainly was in New Orleans at Katrina.
But I want to share a story that started a little bit later.
It was 2012, and I found myself standing in the Emergency
Operations Center in New Orleans being asked by our power
company how to prioritize power restoration for our community.
I was relatively new to the job. It was August. It was hot. We
knew that we were just about 7 years after Katrina, and though
we had done very much to heed the advice of better preparations
and planning, what we had is an event that was not about
flooding but was actually about power outage from prolonged
We were prepared in many ways. We had hardened the
infrastructure, particularly of our hospitals. We have better
relationships, particularly heeding the advice of Senator
Collins of not exchanging business cards during disaster but
doing it well before. And we had done much better planning. In
fact, our hospitals had returned to normal functioning.
The question I was being asked to address was how to
prioritize power for the rest of the community, and the
situation was complicated, of course, because we were getting
reports of seniors struggling in the heat throughout our
community. And we had offered evacuation assistance to many of
those seniors who had been registered in our medical special
needs registry, but they wanted to shelter in place and did not
take the opportunity to voluntarily evacuate.
Though we knew some about them, we did not know where they
were clustered and who was at highest risk and who was
electricity dependent. And so in the end I resorted going door
to door throughout our community to try to help prioritize
power restoration based upon who answered the door when we
knocked on it.
We were able to help a lot of people because we did this
with the support of first responders like fire, but it was not
a great feeling, nor was it very efficient. And so going
forward, we did not want to repeat that experience of having to
be somewhat haphazard in trying to determine how to restore
power in our community, and we worked with HHS to leverage
Medicare data and new technologies like geomapping to be able
to create a map in our community of where seniors who are
We did a drill in the community with fire and police and
volunteers and went door to door to the dots on this map, a
subset of them, knocked on the door, and said, ``We are from
the government, and we are here to help.'' We actually did say
that. I did. And people willingly opened their doors and
learned that we were trying to find out if they were
electricity-dependent and how we could be helpful for them not
only in disaster but every day.
We learned the Medicare data worked. It was accurate. And
we also learned something perhaps more concerning: that of the
some 600 people who were on the list as electricity dependent
for their oxygen, we only knew of 15 of them in our medical
special needs registry.
That system, called ``emPOWER,'' has been taken to scale
and is available to be used across the country in every
community, not only in disaster response but also in
preparedness. And it is an example of how we can use technology
and local experiences married with federal resources to really
do better in preparedness and response. And, in fact, HHS
recently used this tool in Irma and in Harvey.
We do tend to focus on those disasters that make the
headlines and also on those who are most frail and in nursing
homes, but I just want to take a moment to talk about
additional important work that we need to do beyond supporting
those most frail in our community that are in institutions.
When I went door to door in the community after Isaac, the
bulk of the people I saw were individuals that were living
independently, in community-based settings, often in subsidized
housing and high-rises. And, frankly, what I saw was really
heartbreaking. These are people who are living on the edge
every day and are not likely to be broken only by a major
disaster but by, frankly, all the little disasters that touch
their lives on a regular basis. And tools like emPOWER are a
great way to get them on a medical special needs registry so we
know how to find them, but they require human touch as well,
and that is part of the resiliency building that we all need to
I agree that since Katrina we have made a great deal of
progress in hardening our infrastructure, in building the
relationships that are necessary to help us better prepare and
respond, but there is so much we still need to do to support
our seniors. And in that vein I offer actions in three areas
that I think can help build a stronger infrastructure. There is
more in my testimony, but I will just highlight a few today.
One, is tools like emPOWER remind us that we have now
technology and data, but it is only as good as the data in it.
So, for example, in emPOWER, if we expanded it to include
Medicaid and commercially insured populations, we could do more
good for more people. And Congress needs to support the action
on the ground. It is one thing to have information in a box,
but we have to also be able to act upon it on the front lines,
and that requires training exercises perhaps with local public
health and the Public Health Service Commission Corps.
Second, we need to support the local public health and
response infrastructure. They are under-resourced to meet their
statutory obligations to support the community and the most
vulnerable in times of need. This includes public health, but
other agencies and the private sector who are trying to help
seniors and older Americans every day.
Third, we need to do more to protect. I think the CMS
Emergency Preparedness Rule is a step towards strengthening the
infrastructure, but it requires robust implementation. It is
not pieces of paper and checklists. It is actually really
drilling and paying attention in an ongoing fashion to things
like fuel supplies for generators.
And, finally, I think the administration should think about
creating best practices tools that can help guide policy and
regulation and local ordinances that can support areas that
sometimes we forget about for preparedness like building codes.
Thank you again for raising the profile of the need to
better support seniors, older Americans, and the most
vulnerable in our community in times of disaster, but also
every day, and I look forward to your questions.
The Chairman. Thank you very much, Doctor.
STATEMENT OF KATHRYN HYER, PH.D., PROFESSOR AND DIRECTOR,
FLORIDA POLICY EXCHANGE CENTER ON AGING, SCHOOL OF AGING
STUDIES, UNIVERSITY OF SOUTH FLORIDA, TAMPA, FLORIDA
Dr. Hyer. Good morning. On behalf of my colleague Dr. David
Dosa, who could not be here today, I want to thank all of you
for being here and for giving me the opportunity to testify on
a topic I have studied since 2004 when four hurricanes
traversed Florida in 44 days. Since that time, my colleagues
and I have studied the effect of disasters on frail older
adults and disabled individuals living in nursing homes and
assisted living, and we have worked to improve disaster
preparedness, response, and readiness.
My remarks reflect more than a decade's worth of research
that has been carried out with generous grants from the John A.
Hartford Foundation, the Kaiser Foundation, the Borchard
Foundation, and the National Institutes of Health,
specifically, the National Institute on Aging.
In 2004, as Senator Collins alluded to, nursing homes only
became part of the State Emergency Response System after
repeated hurricanes crisscrossed the State, and emergency
personnel finally recognized that nursing homes were actually
health care facilities, taking care of frail elders. ESF
recognized nursing homes needed help getting fuel for
generators, getting power restored. Only then were nursing
homes recognized as part of the health care provider system.
They were ignored until then.
Following Katrina, our research team interviewed nursing
home administrators about their experience during Katrina.
Across the board these nursing home administrators revealed
that they wrestled with the important decision about whether to
evacuate their residents prior to the storm. They cited
pressure from emergency managers urging them to evacuate
despite the difficulty of evacuation, having elders pushed on
buses, having them evacuate to gymnasiums without supplies and
adequate materials and mattresses. And they recognized that
these patients declined. They saw their own staff hurt trying
to help and move residents. And they believed that they would
be better served staying where they are.
This initial work became the impetus for the National
Institute of Aging's study that we did looking at the effects
of Hurricanes Katrina, Rita, Gustav, and Ike on nursing home
residents. Our research showed that among 36,000 nursing home
residents exposed to those gulf hurricanes, the 30- and 90-day
mortality and hospitalization rates increased considerably
compared to the non-hurricane control years regardless of
whether they evacuated or sheltered in place. In total, there
were 277 extra deaths and 872 extra hospitalizations within 30
days after exposure to the storms. Natural disasters result in
bad outcomes for elderly and disabled individuals.
Our research, however, asked a second question. We asked
whether or not it was better to evacuate or shelter in place.
Using those same data from those four storms and methodological
techniques that are in the appendix that we have provided, our
research concluded that the very act of evacuation prior to the
storm increased the probability of death at 90 days and
increased the risk of hospitalization, independent of all other
factors. It should be noted that our data took into account the
fact of certain nursing homes that did not evacuate, including
St. Rita's and Lafon Nursing Homes where there were,
tragically, many deaths.
Despite these tragic deaths, evacuation proved to be
cumulatively more dangerous than sheltering in place. Based on
our research and our experience, we have the following
We need generators to support medical needs and air
conditioning to cool reasonable temperatures as well as fuel
for both nursing homes and assisted livings. These generators
need to be elevated to ensure continued operation. Emergency
plans for both nursing homes and assisted livings must be
publicly and easily available for all to see and for residents
and families to understand before they enter a nursing home.
Nursing home surveyors and emergency managers also need to
be sure all plans are actually tested, and this means real
drills and actual implementation.
Assisted living communities require much more oversight.
Assisted living communities routinely accept patients who would
have received care in a nursing home only a decade ago.
Waiver payments for residents with Medicaid have also
increased, thereby making the Federal Government at least an
interested party in assisted living regulations.
Evacuations should not be all or nothing. Senator Collins
already talked about the importance of dialysis residents being
evacuated. We need a much more nuanced and better researched
understanding of who should evacuate before and then how people
can be sustained appropriately.
Nursing homes and assisted livings must be built in places
that minimize flooding, and they have to be built to standards
that allow administrators to shelter in place if at all
Every state and local emergency management organization in
this country must identify and prioritize nursing homes and
assisted living communities for restoration of power services
and other services.
Some degree of litigation protection must be considered for
facilities that abide by regulations and provide heroic care
during disaster scenarios. There are many people working very
hard to try to care for elders and disabled people all over
Florida, continuing as we speak.
Finally, older adults matter. I am the PI on a HRSA
Geriatric Workforce Enhancement Program grant. We need
continued commitment to geriatric education programs and
training programs. I can only provide the evidence I am
providing today because research and training was approved
years ago, but it dried up in the years following Katrina. Our
country needs ongoing geriatric training. We need consistent
research funding to evaluate disasters. We know that disasters
will continue to occur, and we must be prepared.
Thank you for allowing this testimony, and I look forward
The Chairman. Thank you very much.
STATEMENT OF PAUL TIMMONS, PRESIDENT, PORTLIGHT INCLUSIVE
DISASTER STRATEGIES, INC., CHARLESTON, SOUTH CAROLINA
Mr. Timmons. Thank you, and good morning. Portlight is the
Nation's only NGO with a specific mission to serve the disaster
relief needs of people with disabilities and older Americans.
Portlight is a 20-year-old grassroots organization with a proud
history of serving on the ground in virtually every major
national disaster since Hurricane Katrina. Our Partnership for
Inclusive Disaster Strategies leads and coordinates over 100
disability, aging, emergency, public health, public safety, and
other local, State, and national stakeholder groups, including
FEMA and the Red Cross, with a shared commitment to the
emergency preparedness and disaster-related needs of the
Nation's 59 million people with disabilities and 67 million
Americans over the age of 60.
We have been convening stakeholder calls daily to identify
problems and find solutions and operating our hotline to assist
disaster survivors from Harvey and Irma, and we are currently
preparing our incredibly dedicated volunteers for Hurricane
Given that people with disabilities and older adults are
two to four times more likely to die or be seriously injured in
a disaster, the urgency of our work cannot be understated. This
is due frequently to poor planning, inadequate accessibility,
and the widely shared but incorrect assumption that people with
disabilities and older adults are ``vulnerable,'' ``special,''
or ``particularly at risk'' simply because of their diagnoses
or stigmatizing beliefs about disability and aging. In fact, we
are extremely valuable experts on emergency problem solving,
with far more practice than younger people and people who do
not navigate inaccessible environments and programs on a daily
The appropriate approach focuses broadly on the access and
functional needs of people with and without legal disability
rights protections. In a disaster, providing equal access and
meeting functional needs makes the difference time and again
for individuals, families, and communities. In fact, the phrase
``people with access and functional needs'' has been codified
by DHS and is the work term of art among emergency management
professionals, and it perfectly fits our discussion here.
Ineffective and inappropriate evacuation, hospitalization,
nursing home admission, and separate sheltering and strategies
for assisting millions of people with access and functional
needs might look right on papers; however, it is a deeply
flawed approach in practice, and it must be stopped. It has
been clearly proven in story after disturbing story to be even
worse than we expected. Here are a few examples of the
consequences and shortfalls in accessibility and the
disproportionate impact that is the result.
A Florida man with quadriplegia using a power wheelchair,
separated from his fiancee and was sent to a special needs
shelter, then discharged without any assistance or plan other
than to return to his destroyed dwelling. He had to sleep
outside for several nights until the temperature caused him to
have heat stroke. In partnership with the FEMA Disability
Integration Advisor, we have assisted him to obtain temporary
sheltering in a wheelchair-accessible hotel room.
A woman called from a nursing home she had been transferred
to after evacuating from Houston to Dallas. She told us the
nursing home wanted her to sign over her Social Security and
FEMA benefits, which would make leaving the nursing home
impossible. We have connected her with legal assistance to
protect her rights and address her need to return to Houston as
soon as housing can be found.
Many older adults and people with disabilities in
highrises, trailer parks, and other locations have been
disconnected from response and relief resources, and still are,
and have had no food, water, or power. Our community-based
partnerships have been their saving grace time and again.
In my written testimony submitted for the record, I have
enumerated a short list of recommendations and impactful
actions to improve our national approach to whole community
inclusive emergency preparedness and disaster response. In
summary, we are calling for the establishment of a national
commission on disability and aging emergency preparedness and
disaster management to take the many lessons observed and turn
them into whole community inclusive actions.
For the 59 million Americans with disabilities, including
over two million in nursing homes, and the 67 million Americans
over age 60, providing equal access to emergency services and
programs is not just the right thing to do or simply smart
business practice; it is also a legal obligation. People with
disabilities have a legal right to equal access and
nondiscrimination. Our civil rights are not waiverable. There
is no disaster loophole that allows for the suspension of our
civil rights. Ensuring the federally mandated civil rights of
people with disabilities will well serve everyone with access
and functional needs. A national commission on disability and
aging emergency preparedness and disaster management will serve
to leverage the priceless expertise of those of us most
impacted and will manifest the mantra of the disability rights
movement which applies to everyone with access and functional
needs. Nothing about us without us.
The Chairman. Thank you very much, Mr. Timmons.
STATEMENT OF JAY DELANEY, FIRE CHIEF AND EMERGENCY MANAGEMENT
COORDINATOR, CITY OF WILKES-BARRE, WILKES-BARRE, PENNSYLVANIA
Mr. Delaney. Good morning, Chairman Collins, Ranking Member
Casey, and members of the U.S. Senate Special Committee on
Aging. Thank you for inviting me here today to discuss how
cities and towns across the country can help ensure the health,
safety, and resilience of older Americans and individuals with
disabilities during and after disasters.
I am the fire chief for the city of Wilkes-Barre,
Pennsylvania. I have been honored to serve the city in this
role for over 12 years and have a total of 36 years in
emergency services. I am also the emergency management
coordinator for the city of Wilkes-Barre and a certified
Over 40,000 people reside in Wilkes-Barre, a city located
in Luzerne County. Nineteen percent of the county's residents
are over 65, which is 3 percent higher than the average in the
State. And many of the older residents are concentrated within
the city limits.
Like any fire chief or emergency management coordinator, I
feel a great sense of responsibility for these older
Pennsylvanians, many who live by themselves.
My concern for their well-being is heightened whenever
there is a threat of a severe storm or weather event. That is
due to a 10,000-square-mile watershed that drains into Wilkes-
Barre from the Susquehanna River, threatening to flood our
streets and our neighborhoods.
In 2011, the threat became very real as the east coast
braced for Hurricane Irene and Lee to make landfall. What
transpired over the next week explains why early weather
tracking, data, surveillance, and the flow of information
across all levels of government is a priority and critical to
the health and safety of our residents.
About 7 days before the storms were scheduled to hit, we
heard from the National Weather Service, Mr. Dave Nicosia. They
started to send us regular updates about the storm patterns and
the possible rainfall and potential crests of the Susquehanna
River. The Pennsylvania Emergency Management Agency
disseminated critical data to the county emergency management
officials and the emergency management coordinators for our
Wilkes-Barre is protected by a U.S. Army Corps of Engineers
levee to a river level of approximately 42 feet. The
Susquehanna River crested on September 9, 2011, at a record and
historic level of 42.66 feet.
For years, the gauges that measured the water height of the
Susquehanna River in Wilkes-Barre were broken, and they were
the responsibility of the U.S. Geological Survey.
Senator Casey led the charge here in Washington to secure
the resources to replace our broken gauges. It is because of
Senator Casey that we can track, in real time, the possibility
of a flood and critical river level data. This type of
surveillance information provided the needed data to make risk-
based decisions for possible evacuation.
Using maps of flooding that took place in 1972 after
Hurricane Agnes, we created an evacuation zone. And on
September 9, 2011, we successfully evacuated 15,000 residents
of Wilkes-Barre in about 10 hours. This evacuation included
Wilkes-Barre City Hall, Wilkes-Barre Police Headquarters,
Wilkes-Barre Fire Headquarters, as well as the entire downtown,
including King's College and Wilkes University.
We alerted the local hospital and two nursing homes in the
evacuation zone. They executed their Emergency Preparedness
Plans and safely evacuated 250 seniors. And if at any time they
thought they were going to have trouble evacuating in the time
required, they knew to request additional help from the Wilkes-
Barre City Emergency Operations Center. We would send
ambulances and personnel to help if needed.
But it was the older Pennsylvanians, the seniors, and those
with disabilities who still lived in their homes and in the
community that I worried most about--the Mr. and Mrs. Smiths,
the Mr. and Mrs. Joneses, who have lived in their homes for 50
In preparation for a possible evacuation, we developed a
grid designating areas of responsibility for the Fire
Department, for the Police Department, and members of the
We drove through South Wilkes-Barre and the downtown making
announcements from our vehicles, knocking on doors, and posting
evacuation orders. We knocked on every door. We left notes on
doors of the homes where no one answered and made an additional
check to ensure their evacuation. Most people heeded the
request to evacuate on the first try, but if anyone resisted,
they took their names, wrote down the addresses, and we spent
additional time working to get them out of their homes.
We successfully executed our plan because of the seamless
collaboration and communication among officials at the
national, state, and local levels.
But even so, after every major event, we look back and
discuss how can we improve. For example, should we ever need to
evacuate again, we now have a contact in place with a local bus
company that agreed to drive routes throughout the city to pick
up people and take them to safety.
Following Hurricanes Harvey and Irma, I hope that Congress
will conduct its own after action review as it did after
Hurricane Katrina in August of 2005. While Presidential
Directive 5 started the advancement of the National Incident
Management System, it was for the most part put into action
after Hurricane Katrina and is now the model for how all levels
of government manage all types of emergencies and disasters. As
part of that review, I hope that Congress will commit to
continue to fully fund the National Weather Service and FEMA
and invest in surveillance tools so that we have the most
comprehensive information available before, during, and after a
disaster to guide our decisionmaking. Without early weather
surveillance, we have little time to plan and prepare for
potential weather events.
I am grateful to the Senate Special Committee on Aging for
the opportunity to add my voice to this conversation here
today, and I thank you.
The Chairman. Thank you very much, Chief, and thank you for
reminding us that while our neighbors to the south tend to be
disproportionately affected by weather disasters, we who live
in the Northeast are not immune either. How well I remember the
historic ice storm of 1998--I had been in the Senate for a
year--which left so many of my constituents without power for
so long and required the opening of emergency shelters through
much of the State. So the point is it can happen anywhere, and
all of us need to be prepared. So thank you for recounting your
experience as well.
Dr. DeSalvo, I was very interested in learning about the
emPOWER program, which you have been so instrumental in setting
up and sharing with other states. Obviously, electrical power
is key. It is key whether we are talking about air conditioning
in Florida or we are talking about keeping warm in Maine.
What other gaps do you see that seniors and disabled
Dr. DeSalvo. Senator, a tool like emPOWER that uses medical
claims data gives us a sense of people's health on a population
level, so it can identify not only people who are electricity
dependent but also people who are on dialysis, individuals who
have ambulatory challenges, may be wheelchair bound, as an
example. And in New Orleans, when I was health commissioner--
and we still use it regularly--it is a way, for example, if
there is a boil water advisory, that we are able to target
individuals who might be on special feedings or on dialysis,
and we want to forewarn them in advance of water issues. So it
is not just for electricity.
But, on the other hand, it has to be used, and I cannot
emphasize that enough. Just because we want to try to make the
evidence-based decisions and we want to use data in respectful
ways to identify people at risk, there have to be humans on the
other end that can take that information and make use of it by
making phone calls, by going to people's doors. But really the
opportunity is pretty great not only in big disasters but in
the smaller ones that communities face every day to try to
target limited resources to reach those who have the highest
The Chairman. Thank you.
Dr. Hyer, you gave an excellent explanation of the dilemma
that many long-term care facility administrators face when
deciding whether or not to evacuate, and I remember reading of
the controversy over the mayor of Houston's decision to not
order an evacuation; and yet in other cases where evacuations
have been ordered, more people died in automobile accidents
trying to get out of the area. And I can see you are nodding in
agreement, so I am saying that for our court reporter here. So
the act of evacuation, while totally appropriate, in many cases
can actually be more dangerous than sheltering in place. And
you talked about what is needed, however, for people to safely
shelter in place. We have also talked about seniors who simply
may be very fearful or unable to evacuate.
So give us a little more guidance on how you would advise
public officials or nursing home administrators to make the
critical decision between sheltering in place and evacuation?
Dr. Hyer. Thank you, Senator Collins. Yes, with Rita, there
were 22 people who were killed in that bus as they evacuated.
I think it is a very complicated but critical question. The
emergency management people that I work with say ''you run from
the water''. If you expect that there will be high levels of
water and you cannot maintain safe care of residents, then you
should leave. But those emergency managers ask if ``you can
hide from the wind''. I think we need to think about having
buildings built in places that are appropriate and can sustain
usual low level disasters. I am not sure that nursing homes
should stay, if a Category 5 hurricane is coming in directly at
them. It is just devastating.
However, I think for the most part, many buildings can, in
fact, shelter in place appropriately. In countries--in Taiwan,
they build water gates, and that is exactly what they did in
Houston. And people will evacuate up onto higher floors. You
can stay within the building, but be sheltered on a different
floor. Now, that requires a lot of planning and a lot of
forethought. It also requires you to make sure that you have in
place the necessary equipment and food and water. Those are
usually in place for nursing homes. Those regulations have been
in existence for a long time. But one of my colleagues in
Florida always says you shelter in place until you cannot
shelter in place. Things happen after storms. There were 40
evacuations in Florida of nursing homes after Irma. Some of
those were because trees fall, things happen, winds rip open
roofs, and the place is not safe, it becomes inhabitable. Those
evacuations are appropriate.
But many of those evacuations occurred because power was
not restored, because there were not generators, or the
generators were not appropriately built in a way that they can
sustain residents. There was not enough fuel.
Those regulations have been changed by CMS for nursing
homes, not for assisted livings. I do not even know if assisted
livings in Florida are required to have generators. Assisted
livings really are under the radar.
So I think the answer is that you want to be able to have
people stay in the building, but the building has to be
hardened. They cannot be built in flood areas that routinely,
in heavy storms, continue to flood. And there are building
codes that allow that to occur.
We also need to have them hardened and have generator
capacity. Some buildings are very old. Many nursing homes in
this country are very old. And I think we need to think about
if we are going to allow capital to be used to replenish them
or if we have got certificate of needs, replacing some of them,
I think we need the new buildings to require generators with
sufficient capacity to run air conditioning and other support
systems for a period of time. And 96 hours is what hospitals
are required to have.
The Chairman. Thank you very much.
Senator Casey. Thanks very much. I will start with Chief
Chief, first of all, thanks for being here and thanks for
your testimony and your continued leadership doing a tough job.
We are grateful for that.
I have a good recollection of what we all saw in 2011 in
your home county, Luzerne County. I cannot remember how many
counties I went to, but we had northeastern, central, and
southeastern Pennsylvania, almost virtually half the State,
affected by--and I want to use the right terminology. Irene was
a hurricane, Lee was a tropical storm, I think technically,
Mr. Delaney. They were both bad.
Senator Casey. The combination was terrible. And for me, it
was an eye opener because I had never been affected personally
by a terrible storm or a flood. And even as a public official,
I am not sure I had ever been as close to it as I was in 2011
when we would be walking through those communities in most
cases a few days after, I guess in some maybe only hours. But
what I learned from that is just how violating that is or how
devastating that is in a very personal, even emotional way.
I remember a friend of mine who was kind of the ultimate
tough guy, never bothered by anything, always confident, even
cocky about everything. I walked up to him--his house had been
flooded, and I walked up to him and said, ``How is it going?''
He just dissolved in tears. This really tough, tough guy just
was absolutely devastated. So that gave me an insight, I guess,
into the horror of it, and what we saw in Texas and Florida and
we are seeing all these days in all these other places is maybe
even worse than I saw in 2011.
So one point that you made was the importance of good data
and to informed decision making. We worked together, as you
mentioned, on the stream gauges and helping to gather
information. Talk to us about what data you use to inform your
decision making when you have got an emergency, in this case an
impending hurricane. What data do you use?
Mr. Delaney. This is not really hard. We start with the
critical data, hydrological data from the National Weather
Service. That is why I say that agency is critical for the
information that they send to PEMA, the Pennsylvania Emergency
Management Agency, down to the Luzerne County Emergency
Management Agency, and that flow of data to us. They have some
of the best scientists available that can predict what the
rainfall will be, what the river cresting will be, and that
data we use for risk-based analysis to decide whether we are
going to evacuate or not. And as you know, the river gauge that
did not work almost crippled us where we did not know what the
river was doing.
So I think from an emergency management standpoint, we can
prepare for a lot of these disasters because we have some of
the best scientists in the world that can predict what is going
to happen. So we take that data. We make sure we have our
emergency operations plans. We make sure we write a plan with
our municipal officials. In particular, for Lee and Irene,
Luzerne County opened their Emergency Operations Center early
on because of this prediction, which set the National Guard
there in place so that if we needed to evacuate, that tool was
already there to help us.
So I think a lot of the surveillance data is critical for
that flow of information to come down, number one. And, number
two, the National Incident Management System and unified
command is used to make decisions. So I am the emergency
management coordinator, but I have a boss, and he is the mayor.
And we have a city administrator; we have department heads. In
emergency management, one person does not make the calls. You
talked about sheltering in place. We had a small fire in a
nursing home in Wilkes-Barre two weeks ago, and we decided--it
was only a really small fire--to shelter in place. We probably
had ten decisionmakers there to help make the decision on what
the best well-being would be for the 166 residents that lived
in that place.
So we have systems in place. We really need to use them and
use them adequately.
Senator Casey. I know I am almost out of time. I was going
to ask you as well about sometimes we think of, as you point
out, response tools being things, equipment, whether it is to
remove downed trees--but the challenge you have is having
enough personnel, enough manpower, human capacity, human
infrastructure to be able to go door to door. Talk to us about
Mr. Delaney. Sure. On a daily level, you know, we have 12
to 14 firefighters and paramedics working and maybe the same
amount of police. But by getting this surveillance information
data, we can go to our bosses, our elected officials, and say,
``Listen, we need to prepare. We need to have all 80
firefighters at work for the next 3 days.'' We did that during
the disaster--I should say the winter weather event, the
blizzard we had in northeastern Pennsylvania this past year, we
So, you know, to make these decisions, that information
early on, and I always have to put my request in for AFG and
SAFER, the Federal programs that help us to have the proper
staffing. My department does about 11,000 calls a year. We are
set up for all hazards. But we deliver babies, we put fires
out, we rescue people from the river, we take care of hazmat
incidents, we take the tree branches--we do all those things.
So, yeah, staffing is critical. This early information early on
helps us to have the right amount of people to handle the
Senator Casey. Thanks, Chief.
The Chairman. Thank you very much.
Senator Cortez Masto?
Senator Cortez Masto. Thank you. First of all, let me just
say thank you to Chairwoman Collins and Ranking Member Casey
and all of you here. It is such an important topic, and I so
appreciate the conversation this morning.
I had the opportunity to work in state and local government
in the State of Nevada, and I think people do not realize how
important emergency management at the local, state and federal
level is. And people are working every day so hard to get it
right. God forbid something should happen, but they want to
make sure they get it right. And many times the emergency
management services are underfunded or they are challenged, and
they need more support.
I have a couple of questions, because it came to my
attention that the Department of Housing and Urban Development
recommends, but does not require, that public housing
authorities establish emergency preparedness and response
plans. I am curious if you are aware of this, and/or in your
own communities, how have you brought in some of those
vulnerable populations that live in some of the housing that is
established through HUD?
Dr. DeSalvo. Senator, I want to take this opportunity to
thank you for raising the issue of HUD and housing because it
is a great reminder to us that emergency response is more than
people in uniforms with lights and sirens and even public
health and health care officials, that there are a lot of
people who have roles to play in a lot of agencies. And housing
in particular, I think what you have heard thematically here is
that that is a place where we can do a lot of good if we
prepare properly and think about building code and building
preparation, whether that is elevating generators or thinking
about having exit lighting that is available as part of the
In addition, though, what HUD has access to is a lot of
information about people who live in the housing, and so better
communication and coordination of what they know about the
disabilities or the special needs of people in housing could be
of great benefit to the people who are on the front lines, and
also in between, building resiliency, making sure that people
have the kinds of supports so they can individually be
I just want to point to an example more recently where HUD,
I think, leaned in quite well, and that is in Flint, Michigan,
where when we were trying to understand how to reach kids and
families to let them know about opportunities to get screened
and treated for lead poisoning, that the HUD agencies locally
were able to get their databases and know where there were kids
and helped direct resources. So I have seen it in action in a
slower-burn emergency, but I think there is a lot of
opportunity at the federal, state, and local level to better
coordinate the information and the resources.
Senator Cortez Masto. And I appreciate that because I think
just like your interaction in gathering the data and working
with Medicare to identify a population, HUD can do the same
thing. Federal agencies have access to this data that can help
emergency management at the state and local level as well, and
I think there needs to be more of that partnership.
And so that is why, Mr. Timmons, when you talked about
needing and recommending a national commission--can you talk a
little bit more about that? And is that your thought, that
there is more of that interaction and that sharing of data and
information with the state and local emergency management
Mr. Timmons. That is exactly right, Senator. In my mind,
this comes down to planning, and I differentiate between plans
and planning, much as General Eisenhower did. Plans are
worthless. Planning is invaluable. It is not a matter of just
creating a plan and hitting the print button. I think we need
to be in a perpetual state of planning, and some sort of
national infrastructure to facilitate that I think is critical
to give us consistency and to help us leverage.
The aging and disability stakeholder organizations need to
be involved in this process from the beginning. We are the
experts on what we need, and we are the experts on how to
negotiate getting that in the most efficient fashion.
I would like to see each state have an access and
functional need coordinator within its emergency management
function. We have a couple of models of that in Mississippi and
California, notably, and it is making a tremendous difference.
At the end of the day, I believe this is a relationship
thing. Where we see this work is where there are preexisting
relationships between emergency managers and stakeholder
organizations. Where we see it not work so well is where there
are not, and I do not think it is coincidental.
So what I am suggesting is creating some sort of a
framework to do this in an efficient and effective and
impactful manner. Thank you.
Senator Cortez Masto. Thank you. I notice my time is up.
Thank you so much for the conversation and the work that you do
The Chairman. Thank you so much.
I am going to follow up on the questions that my colleague
just asked. Chief Delaney, let me start with you, and you had
talked about emergency preparedness must start with the
communities. What are some ways beyond looking at HUD data,
which I thought was an excellent idea, that we can involve
organizations--I can think of Meals on Wheels, Area Agencies on
Aging--that have regular contact with seniors in our
communities and would be aware of who would need help or whose
housing might not withstand the blow of a hurricane or an ice
storm or a flood? Are they involved at your level with the
emergency preparedness planning that you do?
Mr. Delaney. Well, there is a lot of individual programs
that are out there, but, again, how do we engage Mr. and Mrs.
Jones, Mr. and Mrs. Smith, who have lived in their house for 50
years? That is a tough nut to crack because when you have to
evacuate 15,000 people in 10 hours, you do not really have the
time to sit and say, ``Well, here is why you have to go,
ma'am,'' or, ``Here is why you have to go, sir.'' That is a
difficult question. If we could get that answered, I would
think we were well on our way.
But I did want to address the assisted living facilities
and nursing home facilities. That is critical that they have
their plans and their plans address how to get out, because
when we evacuated in 2011, we trusted their judgment. We said,
``You have 10 hours to evacuate your facility.'' In their
plans, they have strike forces of ambulances. They have all the
critical data needed to get out. So I think mandating these
plans is critical. I just received a 40 page document the other
day. It seems as though we are getting better at getting these
plans, but there needs to be a regulatory agency to say you
have to have this plan. The local officials need to get this
plan so that we are aware of what is in their plan.
But, Senator, to address you, I think that is a great
discussion to have. The organized facilities have--they know
what to do. It is the average citizen that kind of does not
understand it. They have not talked to folks for days or weeks
about anything potential that might go on. So it takes a long
time. And when we need to get them out, we do not have the
luxury of all that time. So that is a great conversation to
have, I think.
The Chairman. Thank you.
Mr. Timmons, I really appreciate your reminding us that
this conversation on emergency preparedness needs to go beyond
seniors and also focus on individuals with disabilities. What
is your assessment of the level of emergency preparedness in
terms of meeting the needs of people with special needs? Do
they have shelters that are equipped to take care of people
with disabilities? Are they staffed with people who will
understand what they need? This is an area that I do not think
has received as much attention, so I would love to have you
elaborate on it?
Mr. Timmons. So, particularly with the Red Cross, we have
made some progress in the last couple of years in terms of
trying to create an infrastructure, with them working with the
community and with our stakeholder organizations and aging
stakeholder organizations so that all shelters are accessible.
I would again reiterate that in my mind this is a civil rights
issue. So the Red Cross is the primary shelter operator across
the country, and we have seen a tremendous amount of progress
from them in terms of being ready and engaging in planning and
engaging in exercising. And so in a number of places, we are
seeing a tremendous difference. They are sort of the industry
leader in this, and it is my hope that in areas where perhaps
they do not operate the shelters, those who are will learn some
lessons from that.
So we are making incremental gains. It is a slow haul. But
we are beginning to see some understanding, I think, from the
folks in the shelter business that this is a civil rights
issue, that it makes economic sense to make all of the
sheltering and all of the servicing accessible to everyone. It
is a legal obligation. It just makes sense. It is a great
business case. So we are making progress, Senator.
The Chairman. Great. Thank you.
Senator Casey. Thanks.
Dr. DeSalvo, I wanted to ask you about a related topic. We
are in the midst of yet another health care debate, and even in
the midst of that, we have had some good bipartisan work on
health care the last number of weeks, more than two weeks now.
In your testimony you made clear that you have seen in real
time, both in your clinical practice and as a public health
leader, the devastation that a hurricane can cause to seniors
with chronic conditions, as well as individuals with
disabilities and others. So given that experience, how
concerned are you about the latest health care bill that the
Senate is considering?
Dr. DeSalvo. Well, Senator, Louisiana in 2005 was a state
with the unhealthiest population in the country and some of the
highest rates of uninsurance, and access to care for low-income
and high-need people, largely emergency rooms, which prevented
them from having relationships in primary care, so people who
knew about their health and could reach out to them in between
disasters. When they were evacuated, it meant that they arrived
sometimes in other states without any way to get care because
they did not have a way to pay for it, and the absence of
having public or private insurance and having relied in our
state on the charity hospital system. And I will tell you,
someone who has been in Louisiana for decades and have been
telling my colleagues about what it was like to practice in an
environment where your patients were uninsured and you sent
them out sometimes on a hope and a prayer that they were going
to be able to get that colonoscopy or get the medications that
they needed, it was really shocking to my colleagues in other
states that were on the receiving end of these individuals who
had so much medical need and in many cases social need and not
a means to pay for it when they arrived in a new state. And I
think it spotlighted for certainly us in Louisiana but our
colleagues around the country that having a great institution
or place is not the only solution to access to care. You have
got to have an affordable way to pay for your care, not only in
disaster but every day.
So far in Louisiana in the last decade, with the recent
expansion of Medicaid, actually the opportunity for us is less
focused on what is going to happen to those folks who are
uninsured or who maybe do not have the means, than how can we
make the system really work better for them. And I would not
want us to take a step back, not only in Louisiana but as a
And, Senator, if I could, I just might mention the sort of
additional piece that has been raised because it is also part
of the thinking of how to--what may happen in this bill, which
has cuts to the prevention fund, which supports public health
across the country. And public health, an unsung hero in
disaster and every day, literally saves your life every day. It
makes sure you can drink water safely and eat food and be
rescued in the event of a disaster. But it is struggling
already, much less having additional cuts. And it is so
pertinent to this threat of conversation about people with
disability, people who have special needs, because you do not
want to, as in my case, learn about that in the middle of a
disaster. As I showed you in Isaac, you want to know about
those folks well in advance, and you need to be able to
leverage local community organizations who have connections to
those individuals, whether it is Meals on Wheels or the faith-
based community. That kind of coordination and communication
and relationships does not happen just by happenstance. It
requires work and it requires resources, human resources, time
resources, and that requires financial resources to make sure
that local communities have the bandwidth in time to work
together. So I hope that we will not step back, but continue to
Senator Casey. I appreciate that.
Mr. Timmons, I wanted to ask you as well about among your
recommendations is the idea of a federal task force or
committee to coordinate efforts across not only Federal
Government agencies but state and stakeholder groups as well.
What are some of the advantages that communities would see if
planning were better coordinated?
Mr. Timmons. Thank you. In this way I would hope we could
optimize our limited resources, reduce duplication of efforts
that we see, again, create and nurture relationships because
the time to do that is when the sky is blue, and so do that in
a consistent and meaningful way, using people with access and
functional needs as force multipliers rather than seeing us as
liabilities. Planning perpetual vigorous planning and
exercising is something that we would like to see consistently
done around the country. Optimizing health, reducing the need
for acute medical care in these situations I think would be a
tangible result that makes business sense. Universal
accessibility, ensuring the civil rights of people with
disabilities affects the broader access and functional needs
community. So doing this in a consistent, federally mandated,
overarching way just makes sense.
It has been said all disasters are local. There is truth to
that, and in this way I think we could build up the local piece
so that folks like the chief are serving their community and
that people are working together to achieve the goals we are
all after. Thank you.
Senator Casey. Thanks very much.
The Chairman. Thank you.
Senator Cortez Masto?
Senator Cortez Masto. Thank you.
In Nevada, and I am sure in many of your States, we have
rural communities that are challenged--forget just getting
resources there--professionals, you name it, it is--and
geographically challenged. Some of our rural communities it
takes four hours just to drive into, there are no planes, there
is no bus service. And so I am curious how we support a state
in a statewide effort to pull our rural communities into this
emergency management preparedness and if you have any thoughts
Dr. DeSalvo. I will start, and maybe I will spark some
additional conversation. I am really glad that you raised it,
that when you map the challenges in rural communities, it will
overlap with challenges in individuals' resources, access to
transportation, all the things that make them more vulnerable
to disaster. And also our experience in Louisiana is that it
also is a challenge because those may be individuals less
willing to relocate to shelters, particularly if they are
living on the coast. For lots of reasons, cultural and
otherwise, they want to shelter in place. And it is just a good
reminder that there has to be coordination across
Our experience locally was that we had a regular cadence, a
battle rhythm, where--a terrible term, but that is the exchange
preparedness language of each of our local jurisdictions, in
our case parishes, have their own preparedness conversations
about their populations but scaling that across the day to make
sure that we were thinking about regional and then statewide
support and coordination, because this is the thing, and Isaac
is a great example of this. We did not flood in New Orleans
Parish in Hurricane Isaac. We had a power outage situation. But
the parishes just next to us, the counties just next to us
flooded. And so because we were hardened and ready from an
acute-care standpoint and because we were communicating, we
were also hardened and ready to take people from the
surrounding parishes and stand up a medical special needs
shelter to support people. And some of those are pretty rural
environments on the coast. But without, again, those
preexisting relationships when the skies are blue, the
communication infrastructure and everyone knowing kind of what
a sister relationship will look like, we are not really ready
to help each other. And so though it is local, there has got to
be coordination that scales to help bridge the gaps.
Mr. Timmons. In some ways I think maybe the paradigm should
be that we let the local communities draw us into the way they
do this, Senator. There is a lot to be said about the power of
community in some of our more rural areas. I live in South
Carolina. We saw this two years ago with the flood, and we saw
it last week as we experienced some of Irma. A lot of the
things that I am talking about, the broader community
engagement, the local nature of this, is done really well in
our rural communities.
There are some challenges, but there are also some lessons
to be drawn from that that we can apply in other areas as well.
Senator Cortez Masto. Thank you. Thank you very much.
The Chairman. Thank you, Senator.
I want to thank all of our witnesses for your testimony
today and for the really important work that you are doing at
the local, county, and state level, private sector, public
sector, nonprofits. You are all making a difference on the
I also want to thank our staff, which worked hard to bring
this hearing together. We delayed the date of this hearing
because we did not want to interfere with the immediate
response that was occurring in Florida, for example, and in
Texas, because I know from the medical team that helped out in
both places that first responders from all over the country
were assisting in the response, which is a real tribute to the
first responder community.
September is National Preparedness Month, and this year's
theme is: ``Disasters do not plan ahead. You can.'' We should
take that motto to heart, and from this hearing today I can see
the huge amount of progress that has been made since I
conducted that investigation so many years ago into the very
inconsistent and in some ways failed response to Hurricane
Katrina. So we have made great progress, but we still have a
long ways to go.
I love Dr. Hyer's list of exactly the four--I wrote them
down, things that need to be done. I would note that Governor
Scott has issued an order that says that assisted living
facilities also have to have generators and fuel to supply
So we are learning from every disaster, and we are learning
how being prepared today can make the difference between safety
and danger, and in many cases literally the difference between
life and death. For older Americans and those with
disabilities, there are ways to anticipate the unique
challenges associated with aging, mobility impairments, and
medical needs. For seniors living at home, for those in
assisted living facilities, and for those in nursing homes,
there are ways to prepare even though disasters can strike with
little warning, and I think we have learned a lot today about
the importance of communication, working together, and as Dr.
DeSalvo notes, my favorite expression is to say that you should
not be exchanging business cards when disaster strikes. That is
the worst time. And you have to prepare in advance.
I want to close my remarks by also warning the residents
who have been affected by these storms of the many scams that
have already arisen. This Committee has held hearing after
hearing on financial exploitation of our elderly. There are two
scams in particular that seem to be very prevalent.
One is what I would call the charity scam where people are
trying to get donations that purportedly are going to the
victims of the hurricanes but, in fact, are lining their own
pockets. So I would urge people to deal with recognized
charities, to be very careful. And I know the former Presidents
have come together to encourage donations. You can be sure that
is a safe one. But that is a scam that is relentless and
And the other one is an old scam that occurs every time
there is a disaster like that, and that is when people are
pretending to be qualified to repair homes to make them
habitable again and ask for an up-front payment and then they
will do the work. And, of course, they disappear with that up-
front payment and are never heard from again.
So my heart goes out to people who have been affected by
the storms, but I also want to give them a caution to be very
wary of people who would exploit the suffering of others and
the devastation of these storms in order to line their own
pockets. And I just wanted to mention that this Committee will
put out a bipartisan alert to try to raise awareness among the
victims of the storms.
Again, thank you to all of our witnesses, to all of our
members who are here today, and Committee members will have
until Friday, September 29th, to submit any additional
questions for the record.
I should say that both of the Senators from Florida, who
are on this Committee, really wanted to be here today, but they
rushed back to their home state as soon as they possibly could
to help out. And that is certainly understandable as well.
Senator Casey, do you have any closing comments you would
like to make?
Senator Casey. I do. Madam Chair, thank you very much, and
thanks for calling this hearing.
Dr. DeSalvo, Dr. Hyer, Mr. Timmons, and Chief Delaney, we
are all grateful that you are here today and giving this
testimony, bringing real expertise and experience to these
issues. A special thanks to Chief Delaney. We live in the same
home area, one county away, and we are grateful you made the
trip down from Pennsylvania.
I share Senator Collins' commitment to making sure that we
are doing everything, everything within our power to ensure
that seniors and people with disabilities are prioritized in
emergency response in the midst of these horrific challenges.
It should not take the deaths of Americans or the kind of
photos that we saw to cause us to take action and to move this
issue to the top of the agenda, including here in Washington.
That is why we are grateful that we now have legislation that
will begin to address some of these issues.
We need to learn from these tragedies, and we need to
commit ourselves to the goal that they will never happen again.
So I look forward to continuing to work with members of this
Committee on these issues, and we are grateful for this
Thank you, Madam Chair.
The Chairman. Thank you.
Senator Cortez Masto, since you are such a dedicated member
of this Committee, if you have any final words, feel free.
Senator Cortez Masto. No, I am good. Thank you very much.
The Chairman. Thank you. Thank you for your participation.
This hearing is now adjourned.
[Whereupon, at 10:34 a.m., the Committee was adjourned.]
Prepared Witness Statements and Questions
for the Record
Prepared Statement of Karen B. DeSalvo, M.D., Former Health
Commissioner, City of New Orleans, New Orleans, Louisiana
Good morning Chairman Collins, Ranking Member Casey and
distinguished members of the Special Committee. Thank you for the
opportunity to testify today to share my experiences and perspectives
on opportunities to better support older Americans both in times of
disaster and every day. I am Dr. Karen DeSalvo, a physician and former
Health Commissioner for the city of New Orleans.
I am honored to participate in this panel with my distinguished
colleagues. Disaster Preparedness and Response for Older Americans is a
topic about which I have great passion--both as a doctor and public
health professional. Raising awareness of the challenges they face and
opportunities to better support them is a critical conversation.
Though there has been a great deal of progress in the last decade,
more can be done. My goal is to share with you some of my experiences
from New Orleans as a physician and as Health Commissioner and to offer
solutions aimed at building a stronger infrastructure and support
network to improve outcomes for some of the most vulnerable in our
Experiences From the Front Lines
It is now a dozen years since Hurricane Katrina wrought devastation
to my hometown of New Orleans. In New Orleans, though we escaped the
direct impact, our catastrophe was failed flood walls, leading to
inundation of our city with water for weeks and devastation of our
entire health care and public health infrastructure. From 911 to major
hospitals, access and capacity were submerged, along with Charity
Hospital, the primary provider for the poor and uninsured in New
According to a report from the Louisiana Department of Health and
Hospitals, 986 Louisiana residents died as a result of Hurricane
Katrina. Older adults were disproportionately impacted: the mean age of
victims was 69 years with 63% over the age of 65. Amongst the dead were
70 people who died in nursing facilities either during the storm or in
the days immediately following landfall.
I was actively practicing medicine and most of my patients were
older adults. It was a terrible feeling to know that my most vulnerable
patients were disconnected from me, from their therapeutic regimens and
care. At the time, like most of the country we were a paper-based
health care system and those medical records turned to useless bricks.
As people quickly evacuated or later landed in shelters or on rescue
boats, they most often did not have their medicines or even a good list
of them. This meant that essential information to guide clinicians
trying to help displaced patients was not available. And those of us
still in New Orleans did not have the capability to find our patients
easily or to mine data to identify vulnerable patients in need of
There were exceptions; Ochsner Health System and the Veterans
Affairs health system were digitized and, as a result, able to provide
more seamless care such as refilling medications for chronic disease or
preventing gaps in cancer care. The contrast was stark and a great
motivator to us in the health care system to make a transformational
change that would link everyone to a medical home. By digitizing the
health care records, we could have a health system more resilient for
disaster and for every day. This shift would be particularly critical
for older Americans who tend to have a higher burden of significant
medical problems and more complex medication regimens.
New Orleans, like the rest of the Nation, has transformed and now
has a digital health care infrastructure that is increasingly
connected. It also includes patient portals so that people can view
their records to find up-to-date medication lists and medical
histories. This infrastructure was used during Hurricane Harvey in
Houston shelters to access health information in a way we only dreamed
about 12 years ago during Katrina.
Six years after Hurricane Katrina, I had begun my service as Health
Commissioner for the city of New Orleans. It was during my tenure, in
August 2012, that Hurricane Isaac roared ashore in Louisiana some 7
years to the day that Hurricane Katrina had landed. Fortunately, New
Orleans, like much of the country had heeded the lessons learned in the
health care and public health system. We were better prepared. Words
from Senator Collins at the time of Katrina were a rallying cry for me:
`` . . . the last time officials should be exchanging business cards is
in the midst of a crisis.'' My efforts as a physician, advocate and now
public official focused on building a more connected system to support
those in need in the wake of disaster. In the intervening years,
Louisiana and the New Orleans community had developed more targeted
emergency and disaster preparedness planning for older residents and
those with special needs such as those in nursing home settings.
One of these actions by the New Orleans Health Department was the
creation of a medical special needs registry to maintain a list of
those most in need of assistance for evacuation during preparations or
in response operations. We had been working aggressively to shift from
paper to an electronic, searchable version. By 2012, we had improved
our registry of high-risk individuals with special medical needs and
had tripled the number of residents enrolled.
In advance of the storm's landfall, we reached out to these high-
risk individuals directly and through social and traditional media to
offer opportunities for evacuation, providing transportation for those
who wanted to leave. We worked with the dialysis network to ensure that
people accessed dialysis early and we coordinated with newly developed
medical homes to see that people received supports, including adequate
supplies of medications to carry them through potential disruptions of
In the end, Hurricane Isaac did not flood New Orleans proper.
Rather, the challenge New Orleans faced was prolonged power outage.
Hurricane Isaac was a particularly problematic storm for power outage
because it had a large wind field, which remained strong for days. This
prevented repair crews from assessing outages and restoring power. More
than 900,000 customers in Louisiana lost power representing half of the
population. 400,000 were still without power September 1st, four days
The health care system fared well because of improvements in
emergency preparedness made following Katrina. Though some hospitals
lost power early in the storm, their back-up generators functioned as
expected and maintained operations at facilities with very few
exceptions. We were also watching the nursing homes carefully, and
fortunately they reported working generators at their facilities as
As the days dragged on, I found myself standing in the Emergency
Operations Center being asked by our power company to give them
guidance on the prioritizing power restoration. Hospitals were already
on the priority power restoration list and returned to normal function
for their inpatient and outpatient services. The question at hand was
how to prioritize the remainder of our facilities and neighborhoods.
The situation was further complicated by reports that seniors were
struggling with the heat. For a variety of reasons, many high-risk
individuals had not evacuated, despite our efforts to assist those in
independent living situations. This included those in nursing homes and
assisted living, but also people living in subsidized, high-rise
housing around the city.
Without information on where individuals with the most risk were
clustered, we were compelled to go door to door for 3 days to try to
assess need and help prioritize power service restoration. For those
who would, we evacuated them to a newly established medical special
needs shelter in the city.
Leveraging Data and Technology
Following Hurricane Isaac, we worked with the HHS Assistant
Secretary for Preparedness and Response to create more efficient and
effective methods of identifying the most vulnerable in our community,
not only to target power restoration, but also to support them in other
hazards as well. We needed an approach that could scale to support the
approximately 2.5 million Medicare beneficiaries who are electricity-
dependent for medical and assistive equipment.
In June 2013, HHS and the city of New Orleans piloted a first-in-
the-nation emergency preparedness drill. Using Medicare claims data we
identified individuals with electricity-dependent durable medical
equipment and securely disclosed it to a local health department. Along
with first responders (particularly the fire department), we visited
the homes of people identified on the list from CMS as being
electricity-dependent. We wanted to know if Medicare claims data was
accurate in identifying individuals using a home oxygen concentrator or
ventilator. It was 93% accurate. In addition, of the 611 people that
the claims data had identified in the New Orleans community, only 15
were on our medical special needs registry. The drill findings
reinforced our hope that medical claims data could be useful in
improving preparedness and response for high-risk populations.
This effort, now called emPOWER, has been scaled by HHS and is
available to help first responders in planning and response. Every
community can use the map to find the total of Medicare beneficiaries
with electricity-dependent equipment claims at the U.S. state,
territory, county, and zip code level. ``Real-time'' natural hazard and
NOAA severe weather tracking services identify areas that may be
impacted by disaster events and by prolonged power outages.
HHS continues to deploy emPOWER to support communities in disaster
including in the recent hurricanes Harvey and Irma, as well as for
other emergencies ranging from boil water advisories to tornadoes.
Beyond the Headline Disasters
It is easy to focus on the national disasters that make headlines
and on those who seem most frail such as those living in nursing homes.
There is indeed work that needs to be done to ensure their safety in
major events. The added expectations in the Centers for Medicare and
Medicaid Services (CMS) Emergency Preparedness Rule are steps in the
right direction. If robustly implemented by the providers, they could
provide further protections for seniors.
Those older Americans who are not in CMS regulated institutions,
but rather are in community-based settings, living independently are
also at significant risk. These older Americans need our help not only
in disaster but every day. They are exactly the people who wanted to
``shelter in place'' for Hurricane Isaac and likely every other major
event. They want to stay in their homes and will resist evacuation to a
shelter, including one with medical personnel. These are the people
that we should focus on as we work to make the next order improvements
to our disaster preparedness and response plans.
These are the bulk of the people that I saw as I went door to door
after Hurricane Isaac. Many are in federally subsidized housing, living
alone or with other debilitated peers. What I saw was heart breaking.
For many, they were trapped on higher floors, unable to navigate the
stairs to escape when the elevators stopped working because they were
wheel chair bound, dependent on a walker or simply not strong enough.
What was clear was that they were not only isolated because of a
hurricane, but were living on the edge every day. Any small disaster
can easily cause them to decompensate.
Leveraging tools like emPOWER to build more complete Medical
Special Needs Registries is a start. But they also need ``human touch''
on an ongoing basis to help build their resiliency to withstand
disasters large and small. The evidence is clear that older Americans
are more likely to be lonely and socially isolated and those
circumstances are associated with increased risk of medical
complications and death. Efforts underway by national groups such as
AARP's Connect2Affect to address social isolation are an important
start, but these programs should also help link seniors with emergency
preparedness personnel and programs.
Opportunities to Strengthen Preparedness and Response
Though we have made progress, we must do everything we can to
protect the most vulnerable in our communities, with special attention
to older Americans. It is in that vein, that I offer actions that would
build a stronger infrastructure and support network to improve outcomes
for some of the most vulnerable in our community--older Americans.
Leverage Data and Technology
The reach of a tool like emPOWER should be expanded to a broader
group of at risk individuals using data from Medicaid and private
payers. In addition, technology tools like emPOWER are only helpful if
the local officials are aware of the resource and able to use it.
Congress could provide resources to support training exercises by the
Public Health Service Commission Corps to test the use of emPOWER in
communities across the Nation and help prepare the Public Health
Service Commission Corps members to use the tool in disaster response.
Older Americans will be best served when their health information
is available when needed to inform care and evacuation decisions
before, during and after disasters. The infrastructure is in place for
this vision to be a reality but behavior in the health system is
preventing technology from helping people when they need it most. Data
blocking is one such behavior. Congress has already taken action to
advance interoperability of electronic health records and other health
data systems through the MACRA and 21st Century Cures legislation. In
particular, expectations for providers to attest that they are not
blocking data and the additional authorities for HHS are an important
step to improve data flow on behalf of consumers. Congress should press
the Administration to accelerate their timeline to develop educational,
incentive based and punitive measures to address blocking. Furthermore,
Congress should encourage the Office of the National Coordinator for
Health Information Technology in partnership with the Assistant
Secretary for Preparedness and Response to continue working with states
and local communities on efforts aimed at leveraging electronic health
record information for disaster preparedness and response. It is
essential to quickly ensure private and secure data flow for existing
health information given the opportunities on the horizon as new
technologies like telehealth and wearable technology will be
increasingly ubiquitous and able to support older Americans in
preparedness and response.
Support Local Public Health Infrastructure
Local public health agencies are the only health entities with
statutory responsibility to address preparedness and response. But they
are under-resourced across the county, impairing their ability to
support communities, including older Americans. The specific efforts
that are often under-resourced include: Medical Reserve Corps, Medical
Special Needs Registry, and preparedness staffing. Congress could ask
the National Academy of Medicine to undertake a review of needs for
local public health preparedness funding and make recommendations on
approaches to addressing the gap.
Congress should provide resources to support public and private
sector programs that address loneliness and social isolation. The
Medical Reserve Corps (MRC) is one such potential. It is a national
network of volunteers, organized locally to improve the health and
safety of their communities. The MRC volunteers include medical and
public health professionals, as well as other community members who may
not have a health care background. MRC volunteers are an essential tool
to strengthen local public health and improve emergency response
capabilities. They could also be an essential resource to build
individual and community resilience between disasters.
The Centers for Medicare and Medicaid Services Emergency
Preparedness Rule is an opportunity for the public and private sector
to strengthen their all hazards disaster planning. CMS should work with
ASPR, OASH, the CDC and state Medicaid programs to ensure a robust
implementation including mock disaster exercises (table tops) in
conjunction with local public health and/or regional HHS staff.
Disaster plans should also require review to ensure adequate details
such as representation in incident command meetings with emergency
preparedness leads, logs tracking generator maintenance, generator fuel
plans, and transportation contracts for evacuation.
Congress should encourage the Administration to build a best
practices tool kit for local regulation to support the development of
state and local laws, ordinances, and policies that can provide
additional protections for older Americans during disasters. These
might include building permit expectations requiring elevators and
emergency exit lighting be supported by generators.
In closing, protecting those most vulnerable in our communities
should continue to be our priority. Thanks to the combined efforts of
the health care sector and first responders to apply solutions to
lessons learned from previous challenges such as Hurricane Katrina, as
a nation we are better prepared and more resilient to successfully
address disaster response and preparedness for our seniors. We must
ensure an ever more effective and rapid response to disasters that
threaten older Americans. This applies not only to those older
Americans living in institutions, but also to those in community based
settings who can be more disenfranchised and at higher risk. What is
also essential, is that we pay attention to their needs not only in
disaster, but in their every day. Doing so is vital to ensuring that
all communities across the Nation are prepared to respond to and
recover from future public health disasters, fulfilling our collective
promise to never again repeat the chaos, disorder, and despair that
followed Hurricane Katrina.
Thank you again for the opportunity to testify. I will be happy to
work with you on any of these issues as you consider your opportunities
to strengthen support for older Americans. I look forward to your
Questions for the Record
To Dr. Karen B. DeSalvo
From Senator Elizabeth Warren
Climate change is the greatest disaster preparedness and response
issue of our time. A 2016 publication by the Environmental Protection
Agency noted that the consequences of climate changes are serious for
us all, but particularly for older Americans. Additionally, the
nation's population over age 65 is expected to nearly double by 2050,
and approximately 1-in-5 older adults live in an area that was directly
impacted by a hurricane or tropical storm within the last decade.\1\
\1\ Environmental Protection Agency. ``Climate Change and the
Health of Older Americans.'' (May 2016) (https://
You have done considerable work looking at the social determinants
of health--meaning all the social and economic factors that influence
an individual's health.
Is the environment a social determinant of health, and will the
changing climate significantly impact the health outcomes of seniors?
Climate change has a significant impact on the social determinants
of health. Its effect on clean air, safe drinking water, and access to
food and shelter inarguably impacts the health of all Americans,
including seniors. The World Health Organization has declared that
climate change contributes to widening disparities in health equity and
is responsible for 250,000 deaths worldwide each year.
The American Public Health Association has compiled the ways in
which climate change impacts the social determinants of health:
Severe storms and floods can lead to water contamination,
drowning, injury, mold, job insecurity, and vector-borne disease
Extreme heat can cause dehydration, heat stroke,
increased pollution and particulate matter, aggravated allergy and
asthma symptoms, and worsened mental health, including dementia and
Drought-induced wildfires can harm lung and heart health
as well as reduce access to healthy foods.
Seniors experience unique vulnerabilities like low immunity, pre-
existing conditions, and limited mobility that put them at risk for
these and other health threats associated with climate change such as
heart disease, psychological stress, and falls.
As the climate changes--as temperatures rise, air quality worsens,
and flooding increases--what are the particular health risks posed to
older Americans? What are the particular factors that increase the risk
of climate change for older Americans?
Seniors live with a higher physiological risk for heat exhaustion
and cold exposure due to a decreasing capacity to sense changes in body
temperature. As a result, they are less able to adjust to changing
temperatures around them. This is particularly challenging for seniors
living on a fixed income who may not be able to afford adequate air
conditioning or heating.
Additionally, aging has other impacts such as loss of muscle
strength, balance, and cognitive function that renders seniors less
ambulatory. In the event of flooding, power outages, fire, or other
disaster, they may find themselves unable to evacuate timely or at all.
They are also less likely to be able to prepare for sheltering in place
such as by stocking up on food and water since many no longer drive.
Furthermore, hearing and sight loss may interfere with their ability to
respond to disaster preparation or offers of help including
recommendations to evacuate.
Older Americans are also more likely to have multiple chronic
health conditions, which require medications and medical devices for
treatment and support. Power loss will interfere with cooling of
medications such as insulin or prevent use of life-saving treatments
such as use of electronically powered wheelchairs or oxygen equipment.
Finally, because climate change can affect the quality of the air
we breathe, seniors with respiratory conditions such as asthma or
chronic obstructive pulmonary disorder will be at heightened risk for
respiratory distress in events like wild fires that worsen air quality.
From Senator Marco Rubio
Are there new lessons that could be learned from Hurricanes Harvey,
Irma, and now Maria?
In particular, do you have any recommendations as to how we could
better respond to the needs of dialysis patients--whether they receive
care at an outpatient clinic or in their own home?
In order to respond to the needs of vulnerable populations during
disaster, we need to know where they are so that first responders can
prioritize their efforts to address these special needs first. When
utilized, tools like emPOWER provide an unprecedented capacity to
locate and respond to different patients with specific needs, like
those undergoing dialysis. Currently emPOWER is limited in scope, only
identifying individuals covered by Medicare. Expanding this program to
a broader group of at risk individuals by using data from Medicaid and
private payers would help first responders extend their impact in times
of disaster. Of course, tools like emPOWER are only helpful if local
officials are aware of the resource. Resources are needed to support
training exercises by the Public Health Service Commission Corps to
prepare members to use the tool in disaster response.
What would you recommend to the families with loved ones in
assisted living facilities or nursing homes about how to make sure a
particular facility is able to respond to an emergency?
1. Families have an important role to play to see that their loved
ones will be protected in times of disaster. There are a number of
steps families can take to be better informed and to ensure that the
institutions and their loves ones are prepared. They can begin by
asking key questions of facilities. These should include questions
about building readiness in disaster to support ``shelter in place''
and preparedness for evacuation.
2. Families should ask about readiness to support sheltering in
place, particularly regarding power backup system. It is not only
important to ask whether the facility has a backup system, typically in
the form of a generator, but also whether it has the capacity to power
life sustaining parts of the facility such as the elevators and cooling
and heating systems. They should inquire about whether the generator is
raised above the flood plain, how frequently the generator's
functionality is tested, how many days of fuel it can provide, and what
the specific plans for fuel replacement entail. They should also
inquire about staffing plans including access to higher level clinical
care such as through an in-house nurse practitioner or telehealth
3. Communications systems are another important area to inquire
about. They should understand when and how they will be contacted in
the event of disaster. They should also understand whether the facility
will have redundancy in systems supporting telecommunications and
4. Families should also be clear about plans for evacuation in the
event of emergency. They should be clear about whether and how their
loved ones will be evacuated, including asking if the facility already
has a transportation contract in place to support the evacuation. They
should also understand any responsibilities the family may have,
particularly if the family member resides in an assisted living
facility. Additionally, families should inquire about plans for
staffing during evacuation and whether there is a preexisting
arrangement with a ``sister facility'' to serve as temporary shelter.
5. Other actions a family can take include maintaining a list of
doctors, medical problems, and medications. This can be on paper or
electronic, but they should also see that they have access to their
family member's electronic medical record of their primary care
physician through their patient portal. For those family members with
end of life wishes expressed in living wills, they should ensure that
those documents and wishes are known to the facility, accessible
electronically, and known to the family member's physician.
6. Additionally, people should ensure that their family member or
loved one is registered with the Medical Special Needs Registry with
local health department. This is particularly important for seniors
living in assisted living facilities or other community based settings.
This will ensure that they are on a priority list for assistance
before, during and after an event.
Prepared Statement of Kathryn Hyer, Ph.D., Professor and Director,
Florida Policy Exchange Center on Aging, School of Aging Studies,
University of South Florida, Tampa, Florida
David Dosa, M.D., MPH, Associate Professor of Medicine and Health
Services, Policy and Practice, Brown University, Associate Director,
Innovation for Long Term Services and Supports, Providence VA Medical
On behalf of my colleague Dr. David Dosa who could not be here
today, I would like to thank the Senators and the Senate Special
Committee on Aging for providing the opportunity to testify here today
on a topic that I have studied since 2004 when four hurricanes
traversed Florida within 44 days. Since that time my colleagues and I
have studied the effect of disasters on the frail older adults living
in nursing homes and assisted livings and have worked to improve
disaster preparedness, response, and recovery.
I would like to focus my remarks on more than a decade's worth of
research that has been carried out thanks to generous grants from the
John A. Hartford Foundation, The Kaiser Family Foundation, The Borchard
Foundation, and the National Institutes of Aging. My focus will be on
the issue of evacuation of nursing homes; but for background, in 2004,
Florida nursing homes only became part of local and state emergency
management operations after repeated hurricanes crisscrossed the state
and emergency management personnel finally recognized nursing homes
needed help replenishing medical supplies, water, restoring power and
getting fuel for generators to continue to operate.
Following Hurricane Katrina, our research team interviewed nursing
home administrators about their experiences during the storm. Across
the board, these interviews revealed that administrators wrestled with
the important decision of whether to evacuate their residents prior to
the storm or ``shelter in place'' during a hurricane. Administrators
noted to us that they were, ``damned if we do and damned if we don't''
in terms of the decision to evacuate. They cited pressure from
emergency managers to leave their homes despite the difficulties of
evacuating frail older adults on school buses to high school
gymnasiums--often without adequate staffing and supplies. In general
terms, many administrators noted that they saw patients decline, staff
endure injuries moving residents, and believed more casualties occurred
if they evacuated than if they remained in their own facility.
This initial work became the impetus for a National Institutes of
Health sponsored study that evaluated the effect of Hurricanes Katrina
(2005), Rita (2005), Gustav (2008), and Ike (2008) on nursing home
residents. This research eventually showed that among 36,389 NH
residents exposed to the Gulf hurricanes, the 30 and 90 day mortality/
hospitalization rates increased considerably compared to non-hurricane
control years regardless of whether they evacuated or sheltered in
place. In total, there were 277 extra deaths and 872 extra
hospitalizations within 30 days after exposure to anyone of the storms.
While everyone suffers in disasters, our data indicate that exposure to
natural disasters such as Hurricanes Harvey or Irma clearly results in
excess death and hospitalizations among frail populations.
Our research, however, does more than simply evaluate what
hurricanes do to nursing home residents. We asked the simple question.
Is it better to evacuate or shelter in place? Using the data from the
four storms and some methodological techniques described more fully in
our research, we concluded that the very act of evacuation prior to the
storm increased the probability of death at 90 days by 2.7%-5.3% and
increased the risk of hospitalization by 1.8%-8.3%, independent of all
other factors. It should be noted that this data took into account the
multiple deaths that occurred at St. Rita's and Lafon Nursing Homes
during Hurricane Katrina. Despite these tragic deaths, evacuation
proved to be cumulatively more dangerous then sheltering in place.
Why it is potentially more dangerous to evacuate from a hurricane
than to shelter in place? Definitive studies are not available but we
offer several explanations:
1. Hurricanes often deviate from their expected paths after the
decision to evacuate must be made. In general, safe evacuations must
occur at least 48-72 hours before landfall. Unfortunately, hurricanes
make last minute turns and speed up or down. Hurricane Irma was
expected to be a Category 4 making landfall near Miami. Many nursing
homes evacuated west only to be evacuated a second time as Irma's path
moved westward and threatened the very areas that residents had
2. The evacuation of frail older adults is a logistics nightmare
and requires exquisite planning prior to the event. Good materials
exist to help with plans (http://www.ltcprepare.org/) but even under
the best-developed emergency plans, evacuations create anxiety for both
residents and staff that appear to have serious adverse outcomes.
3. Older adults are susceptible to adverse outcomes whenever they
transition from one environment to the next--even under optimal
circumstances. Safe transitions require optimal communication among
providers, keen knowledge of the patient, and access to medical
records, correct medications, and appropriate supplies. In emergencies,
transitions are seldom ideal and we have shown the consequence of such
forced transitions in our hurricane research.
4. Older adults with dementia represent a particular hardship for
evacuating facilities. Without the cognitive ability to follow
directions, or participate in their own self-care, residents with
dementia suffer significantly during evacuations.
5. Common comorbidities such as congestive heart failure, chronic
obstructive pulmonary disease, and various cardiovascular diseases
require clinician's knowledge of the resident, careful observation,
adequate temperature control (e.g. air conditioning), and adherence to
specific medication regimes, physical and occupational therapies, and
specific dietary needs.
6. Medical records and medications are often misplaced or poorly
adhered to during disasters.
7. Evacuations occur after the storm because nursing homes and
assisted living may not be a priority for restoration of power. Florida
had 40 nursing homes and 177 assisted living communities evacuate after
the storm; the majority evacuated because their generators weren't
Based on our research and experience, we have the following
1. Generators to support air conditioning and other medical needs
must be required for both nursing homes and assisted livings. Ideally
these generators need to be elevated to ensure continued operations
during flooding. I am proud that last Saturday, Florida Governor Scott
announced emergency rules requiring a generator and the appropriate
amount of fuel to sustain operations and maintain temperatures at 80
degrees or less for at least 96 hours following a power outage.
2. Emergency plans for nursing homes and assisted livings are not
always available nor understood by residents or family members.
Regulations must require that emergency plans for both nursing homes
and assisted living be posted and available for inspection prior to
admission. More work needs to be done to help people make choices based
on posted disaster plans and to ensure the posted ``plan'' is actually
a workable plan. Optimal preparedness means real drills and plans that
are tested--even if only partially.
3. Assisted living communities require more disaster preparedness
oversight than they currently receive. We know older adults and
disabled people want care in the community in less restrictive
environments. Nevertheless, assisted living communities routinely
accept patients that would only have received care in a nursing home a
decade ago. Waiver payments for residents with Medicaid have also
increased, thereby making the Federal Government an interested party in
assisted living regulations. Currently, we don't even know whether a
particular Medicare/Medicaid patient resides in an assisted living
facility. This inadequacy in disaster response must be rectified.
4. Evacuation must be nuanced and must take into account the size
and severity of the storm, the ability of the facility to withstand
wind and potentially storm surge, and the needs of the residents.
Evacuation should not be ``all or nothing.'' There are times where
certain medically complex patients (e.g., dialysis patients) might be
more optimally treated with early evacuation while other more stable
patients shelter in place. More research to identify the types of
patients that benefit from evacuating or sheltering in place must be
5. Nursing homes and larger assisted living communities must be
built in places that minimize flooding risk and must be built to
standards that allow administrators to shelter in place if at all
6. Every state and local emergency management organization in this
country must identify and prioritize nursing homes and assisted living
communities for restoration of services.
7. Some degree of litigation protection must be considered for
those facilities that abide by the regulations and provide care during
disaster scenarios. Our research clearly shows that hurricanes affect
all nursing home residents, regardless of whether they evacuate or
shelter in place. Unfortunately, this did not prevent many
administrators from being sued repeatedly for the heroic care that they
provided following Hurricane Katrina.
8. Finally, older adults matter. I am also the PI on a HRSA-funded
Geriatric Workforce Enhancement Program grant. We believe that a
continued commitment to geriatric education programs that help the
nation's health workforce better serve the older and disabled
population must be a priority. I can provide evidence today because the
research and training developed after Hurricane Katrina has led to
improved disaster response across the country. However, the funding
rapidly dried up in the years that followed Katrina. Our country needs
ongoing geriatrics training for population aging. We also need
consistent research funding to evaluate the disaster needs of older
adults and develop best practices. We know disasters will continue to
occur and we must be prepared.
Thank you for allowing this testimony.
Questions for the Record
To Dr. Kathryn Hyer
From Senator Marco Rubio
Dr. Hyer, in the recent tragedy at the nursing home in Hollywood,
Florida, we have heard accounts that this nursing home had an emergency
response plan in place and they simply were not following it.
What are some of the ways we can create a backstop for instances
like this, when emergency plans are not adequate or they are simply not
Background: According to the Centers for Medicare & Medicaid
Services (CMS) interpretive guidance, the new Emergency Preparedness
rule becomes effective November 15, 2017. Guidelines were issued in
September 2016 and there were national training on the rule conducted
in March 2017. CMS has good training materials for nursing homes on its
Currently, in Florida, there is diffusion of responsibility between
approval of nursing home emergency plans and the inspection of the plan
in a specific nursing home by nursing home trained inspectors. The
diffusion complicates coordination during disaster preparedness and
during recovery as the Hollywood Hills nursing home exemplifies.
The local county or city emergency operations center (EOC),
generally a part of the Department of Health, reviews and approves the
nursing home comprehensive emergency plan for that area. Then, the
Agency for Health Care Administration (AHCA) inspects the nursing homes
and verifies if the emergency preparedness plan is approved by the
local EOC. During disasters and recovery there does not appear to be a
standard protocol for AHCA participation at the local EOC. As Senator
Collins says ``You shouldn't be exchanging business cards during a
disaster.'' Yet, during Irma, many counties that did not have local
AHCA staff present during the pre-emergency period nor during recovery.
Many AHCA staff had no history of routinely working with the EOC during
non-emergency events. Importantly, routine disaster preparedness drills
and exercises at the local EOC level do not seem to routinely include
local nursing homes, AHCA regional inspection staff in that area, or
At the state level, the Department of Health and the AHCA work
together well, in my judgment. My experience is that during any
emergency, the Emergency Support Function for Public Health (ESF-8),
operated by the Department of Health, is staffed with high-ranking
representatives from AHCA who inspect the nursing homes and assisted
living facilities in Florida. I think the system at the state level is
well coordinated and there seems to be excellent communication between
and among the Department of Health, AHCA, and state associations for
nursing homes and assisted living facilities. These new standards
became effective during the 2004 storms and have been improving since
At the county or city level, the EOC, the Department of Health and
the local AHCA survey office do not communicate routinely and do not
have a history of working together--that is the hallmark of the State's
1. Require the State of Florida's Field Operations for the Division
of Health Quality Assurance within the AHCA to determine if the nursing
home is compliant with the new emergency preparedness rules by using a
survey protocol that has been developed with the EOC.
2. Require generators and fuel for 96 hours. The rule hearings for
both assisted living and nursing homes were held on November 3.
3. Require that EOCs and nursing homes practice the emergency
operations plans and that they report the practices. Require AHCA staff
to be included in the simulations or table tops. To make this
efficient, some coordination could occur using web-based reviews and
participation. But, the plans must include both the Department of
Health and the AHCA staff, as well as nursing home providers.
a. Any exercise should include an actual evaluation of the
exercise using evaluation criteria that are available. (Did the home
use an incident command system and actually use the written emergency
plan when it was conducting its exercise? Did the nursing home submit a
revised plan based on the exercise?)
b. Target and prioritize homes with more intensive emergency
Facilities that have lower quality ratings, such
as special focus facilities, or poor quality stars (one
star) might be required to participate in ``table top''
exercises with others and the EOC.
Facilities in flood evacuation Zone A might also
be required to conduct a partial emergency exercise where
they are required to evacuate one part of a home to
determine how viable the plan actually is and to test how
long it will take.
4. Disaster plans should require a detailed staffing plan--how will
nursing homes supplement staff to meet staffing requirements during
disaster and during the recovery? Irma preparations began on Thursday,
September 7, for most nursing homes in south Florida. Nursing home
staff worked 12-hour shifts during preparation and then the recovery
period began on Monday, September 11. While technically the staff may
have had 12 hour rest periods, many must have been exhausted after 4-5
days of working. Irma was an unprecedented storm because of its size
but we must learn from it.
Emergency plans should include staffing contingency
plans, including who is responsible for high-level administrative
staff, such as director of nursing and administrator during recovery if
those staff leave.
Penalties for not complying with the plan should be
reviewed but clearly the agency already has the authority to close the
facility and move residents to other facilities.
5. New CMS guidelines require nursing homes to have power sources
to keep ambient temperature between 71-81 degrees. However, rules don't
specify how many rooms or areas must be covered. This should be
specified in an emergency plan that includes details for sheltering in
place. If the conditions are not met, the plan should provide how the
nursing home would evacuate. Nursing homes must create plans to
evacuate during recovery if they are not able to care for residents.
Are there ways we could confirm emergency plans are being followed,
apart from just relying on the word of the nursing home?
Florida has good infrastructure for nursing home communication with
EOCs. A review of adherence and enforcement is recommended.
Florida leads the country because it has instituted a web-based
tracking system--FLHealthStat--which is used by AHCA, the Florida
Department of Health, and state and local emergency management offices
to identify issues for all health care providers (hospitals, nursing
homes, intensive care facilities, and assisted living communities). The
FLHealthStat data base preserves information over disaster rather than
the earlier tracking system which updated (overwrote) provider data
until disaster ended.
All nursing homes and assisted living communities must
register in FLHealthStat.
All nursing homes and assisted living communities are
expected to update and report to AHCA in the FLHealthStat system
before, during, and after the storm.
During Preparation: AHCA and EOC use FLHealthStat to
identify nursing homes and assisted living communities with unoccupied
beds that should be able to accept new residents either from the
community or from other providers.
During Recovery: FLHealthStat includes measures of
providers' status and critical needs, including power needs, resident
needs, staffing needs, damage, and water outage.
Re-entry Into Evacuated Home: Nursing homes that
evacuated must obtain clearance from the EOC, fire marshal or AHCA,
depending on if damage was sustained in the facility. If the disaster
plan that was approved by the local EOC is deviated from at all, the
facility must contact the local EOC to communicate the change in the
plan and obtain approval.
AHCA kept requesting associations to help providers to
update information. AHCA is surveying providers to learn about
opportunities for improvement in system.
While FLHealthStat is an improvement over earlier
systems, there were complaints the system was cumbersome.
Potentially, sanctions or penalties for not reporting or
updating the information might be appropriate, after a review of
current rules and opportunities to improve the reporting system.
Dr. Hyer, your testimony mentioned that nursing homes have not
always been part of Florida's local and state emergency management
operations, and they were ultimately included after Hurricane Katrina.
In the days after Hurricane Irma, we heard reports about how a number
of other facilities and providers were not designated as such by the
state, local government, or electricity provider. This including
nursing homes, assisted living facilities, retirement homes, oxygen
providers and others.
Do you know how often state and local governments update the lists
of providers like these so they are able to quickly respond to their
I believe FLHealthStat includes licensed health care providers
including nursing home, assisted living, hospices and home care.
Retirement communities are not included. I do not know if medical
equipment suppliers are included.
Recommendation: Disaster plans, approved by the local EOC, should
be publicly available for all health care providers.
Are assisted living facilities and retirement homes fully
incorporated in state and local government response plans--in Florida
Assisted living facilities are required to have disaster plans and
to register with the Department of Health's web-based tracking system--
FLHealthStat--which is used by AHCA, the Florida Department of Health
and local emergency management offices to identify nursing homes'
status and critical needs.
Recommendations for Assisted Living Communities: I think this is a
new and important area for state and potentially federal oversight and
coordination. Given the current use of assisted living communities for
Medicaid waivers under long-term care supports and services, assisted
living is an increasingly important part of community care. Many of the
small assisted living communities provide care for low-cost and there
are important implications for increased regulations on the viability.
However, given that over 400 assisted living communities evacuated for
Irma, their role in providing care for disabled and older adults is
1. Opportunities for increased coordination between the Department
of Health's EOC and AHCA is harder to achieve with assisted living.
Florida licenses 3,003 assisted living communities with approximately
94,000 beds. Because so many are small homes (under 16 beds), the
ability to thoroughly review plans is more complicated.
2. Assisted living communities are not licensed as health care
providers. They are licensed under Chapter 429 and are considered
``community dwellings''. Licensing requirements are different.
3. Assisted living inspections also occur every 2 years unless
there is a complaint. More frequent inspections, annually, is
recommended. Disaster plans can then be reviewed annually and any
drills can also be monitored.
4. It has been reported that the utility companies did not have
accurate data for some assisted living facilities because they did not
register with the utility company as an assisted living facility. Some
assisted living communities registered as a private home. It is not
clear what the motivation is, but regulations should be reviewed to
determine if assisted living communities must register with a utility
as an assisted living community. It may be important to review the tax
status on things like home-owners exemptions for small assisted living
facilities as well.
5. Assisted living requirements for disaster plans may need more
thorough review by both the EOC and by AHCA inspectors.
6. Assisted living communities disaster plans should be reviewed
carefully by the EOC and made public on the AHCA Web site. New
residents might be required to review and acknowledge they have seen
and understood the disaster plan. Changes to the plan would have to be
sent to all residents.
7. Assisted living fines or sanctions for not complying with
disaster plans need to be reviewed and perhaps changed based on
experience with Irma.
From Senator Bill Nelson
Dr. Hyer, thank you for your research on disaster preparedness in
nursing homes and long-term care facilities in Florida. I am still
devastated about the 12 seniors who died after being trapped in a
nursing home in high temperatures after Hurricane Irma knocked out the
facility's power. The failure to transfer these seniors to a
functioning hospital some fifty yards away is unacceptable.
The Centers for Medicare and Medicaid Services (CMS) finalized a
rule requiring facilities participating in Medicare and Medicaid,
including nursing homes, to update their plans for disasters and
coordinate with government agencies to ensure facilities are equipped
to respond to an emergency. The regulation was finalized in September
2016, and facilities are required to comply with this rule by November
Does the CMS emergency preparedness regulation address some of the
problems that led to the deaths at the Hollywood nursing home? Does the
emergency preparedness regulation go far enough?
The new CMS emergency preparedness regulations require nursing
homes to have alternative sources of power and to have temperatures
that do not exceed 81 degrees when power is lost. How well nursing
homes will be able to comply with the regulations is an ongoing issue
and enforcement is a powerful tool to be certain these rules are
implemented. I believe the state inspectors have to receive additional
training, especially the inspectors who generally do the fire and
safety inspections. CMS guidance is also probably needed to teach
inspectors how to review the plans and be able to determine if the
proposed plan would actually provide the ambient temperatures required
for the residents to be safe.
How important is it for CMS and state governments to prioritize
robust implementation of this rule and ensure facility compliance in
states before another disaster hits?
It is critical for CMS to work with every state to make sure the
state and local emergency management structures for health (ESF-8
functions) include long-term care providers, specifically nursing
homes. I do not believe that all states have nursing homes as part of
the ESF-8 team at the state level. Florida only added nursing homes
during the 2004 hurricane season.
Most local EOCs do not have good representation of nursing homes
within the local Emergency Operations Center. This is a critical
breakdown in systems for two reasons.
1. The new CMS rules require local EOCs to approve the disaster
preparedness plans. If the EOC does not visit or recognize the needs of
the nursing home, the plan can easily become a ``paper exercise'' not
an actual plan that works.
2. The EOC needs to include local nursing homes in the preparedness
exercises. Robust preparedness requires EOCs to work with the nursing
homes in a meaningful way that allows the EOC to protect nursing home
residents and others in the community.
As it is currently structured, Medicaid can respond to public
health emergencies and natural disasters. As the needs go up, whether
it's because more people become eligible because they've lost their
jobs or homes, or their health needs grow, federal funding goes up
automatically in response.
The Graham-Cassidy amendment that was unveiled last week would cut
$1 trillion dollars from Medicaid, according to the nonpartisan
Congressional Budget Office. The bill would create a block grant, which
provides a fixed amount of funding, and would cap the underlying
We've had three hurricanes in a matter of weeks, and the Medicaid
program is especially important to hurricane recovery efforts. I am not
only worried about my home State of Florida under this proposal, but
also how Puerto Rico and the U.S. Virgin Islands will fare. As they
struggle to recover from Hurricane Maria, their Medicaid programs are
subject to a block grant that won't adjust for the greater demands as
the islands recover.
How would the Graham-Cassidy bill provide states with sufficient
funding to respond to natural disaster like hurricanes? What happens
when more people need health coverage or costs rise on a per-
I do not have expertise in this area.
I introduced the Protecting Seniors During Disasters Act with
Senators Rubio, Casey and Collins. The bill would create a national
advisory commission on seniors and disasters to provide expert advice
to the U.S. Department of Health and Human Services on the unique needs
Given your experience, why do you think a national advisory
commission on seniors and disasters is important? Do you believe a
commission like this can strengthen disaster preparedness and response
for older adults?
I think a national advisory commission on seniors and disasters is
important and would identify ``best practices'' across the country that
could be disseminated. It would make a difference because improved
practices heighten the understanding that our nation needs to be
prepared. Such a commission would reinforce the learning that has
occurred since 2004 storms and Katrina.
Prepared Statement of Paul Timmons, President, Portlight Inclusive
Disaster Strategies, Inc.
Chairman Collins and Ranking Member Casey, thank you for the
invitation to speak before the Committee on this important topic. My
name is Paul Timmons, President of Portlight Inclusive Disaster
Strategies. I have been working in the field of disaster preparation
and response for people who are aging and those with disabilities for
15 years and have led Portlight since 1997. In my time I will share
with you some of my observations related to our most recent disasters
and make a number of recommendations for improving disaster
As the news media began to cover the story of the horrific
conditions at the Hollywood Hills Nursing Home in Hollywood, FL and the
deaths of eight of their residents on September 13, Portlight
Strategies had begun our 18th straight day of round the clock disaster
response efforts to address the disproportionate impact of hurricanes
Harvey and Irma on older adults and people with disabilities. Given
that people with disabilities and older adults are two to four times
more likely to die or be seriously injured in a disaster, the urgency
of our work cannot be understated. The disproportionate rate of injury
and death is due to poor planning, inadequate accessibility, and the
widely shared but incorrect assumption that people with disabilities
and older adults are ``vulnerable,'' ``special,'' or ``at-risk,''
simply because of their diagnoses or stigmatizing beliefs about
disability and aging. In fact, older adults and people with
disabilities are extremely valuable experts on emergency problem
solving, with far more practice than younger people and people who
don't navigate inaccessible environments and programs on a daily basis.
Since August 26, our work at Portlight has been spent, around the
clock, organizing lifesaving rescues with our partners, organizing
delivery of food, water, generators, wheelchairs, medical equipment and
supplies, sign language resources, addressing civil rights violations,
answering non-stop calls to our hotline, and pointing people to
lifesaving and life sustaining emergency resources to meet the critical
needs of older adults and people with disabilities.
We have organized daily national, state, and issue specific public-
private coordination calls between governments, the Red Cross,
disability organizations, and stakeholders to optimize limited
resources and minimize duplication of effort.
For every heartwarming tale of heroism (and there are many), we are
navigating the devastating stories from people who have not benefited
from the considerable tax payer investments in local, state, and
national emergency preparedness initiatives. Local resources, the most
knowledgeable daily lifeline for people with disabilities and older
adults, are rarely funded before, during, and after disasters, with
federal funds and donations going to organizations without a local foot
print or experience in meeting the daily needs of older adults and
people with disabilities in the impacted areas.
What has happened since the Post Katrina Emergency Management
Reform Act was passed in 2007?
Great progress was made for many years, primarily by heavily
investing in whole community inclusive initiatives, with true
partnerships between FEMA and disability and older adult led
People with disabilities and those who are aging need to be at the
table when planning for disasters. There is no more important time for
the adage ``nothing about us, without us'' to be a reality. At the
local, state, and federal levels, and in non-profit agencies dedicated
to disaster preparation and response, those who are aging and disabled
need to be both participants and leaders. Right now, most planning
occurs ``FOR'' people with disabilities and older adults, not ``WITH''
us. Moving forward we need to ensure there is substantial leadership
and participation during emergency planning.
To truly include older Americans and Americans with disabilities in
the planning process, the following issues need to be addressed in
order to reduce injuries, avoid deaths, and ensure response is as
effective as possible:
Ensure communication about emergency services are
broadcast and distributed in American Sign Language and clear, plain
language in all cases when communication about a disaster is made to
the general public;
Ensure that all emergency response communications,
including 911, 311, and 211 emergency and information lines are
Ensure all building evacuation procedures include
procedures for those who need mobility support, have sensory
disabilities, intellectual disability, and anxiety and other mental
health concerns, and that personnel are trained to implement those
Ensure that all transportation to evacuate older persons
and those with disabilities are fully accessible, have personnel who
know how to operate the vehicles and the accessibility features, and
are available during the emergencies;
Ensure access to food, water, medicine, and power;
Ensure all information about what to do, where to go, and
how to get help is available in accessible formats, including video
with captioning, audio, and plain language formats;
Ensure all shelters, including both general population
shelters and ``special needs'' or ``special medical needs'' shelters,
are ready to support older adults and those with disabilities and that
personnel staffing those sites are trained to support people with
disabilities and those who are aging;
Ensure all shelters are accessible and have trained
personal assistants, accessible showers and toilets, flexibility in
meals to meet dietary restrictions and requirements, and equal access
Ensure admissions to medical facilities and nursing homes
are not substituted for meeting civil rights obligations to provide
equal access to emergency services and programs in their community;
Ensure that all tracking information systems are up-to-
date and personnel know how both to use the systems and maintain
Ensure there is equal access to emergency registries
operated by state, federal, and non-profit emergency programs;
Ensure voluntary registries are not only used in
preparation for a disaster but are actually used as part of the
Significant delays (up to 30 days, if the caller could
even complete their call) in receiving ``critical and immediate needs''
assistance from FEMA and Red Cross, despite announcements to apply;
Ensure individuals who use service animals are admitted
to shelters and are able to stay with their animals while in shelters;
Ensure individuals who use mobility devices, sign
language interpreters, personal assistants, communication devices, and
health maintenance items are not separated from those devices and
Despite extensive planning, many of these items were not completed
for the response to Harvey and Irma. We learned lessons from Katrina
and Sandy but did not implement many of those lessons. Hopefully we
will be able to implement more lessons from the most recent storms. The
following are my priorities to improve responses to reduce injuries and
1. Create an inclusive disaster relief fund for Independent Living
Centers and other consumer controlled community disability and aging
organizations to engage in emergency preparedness, response, recovery,
and mitigation. Invest $1 billion over 5 years to serve the people of
their community before, during and after disasters. Those who are aging
and those with disabilities are the experts on housing, access to
health maintenance services, accessible transportation, getting people
back to work, and keeping people out of nursing homes. Currently,
independent living centers and other consumer directed agencies receive
no funding to do their emergency preparedness and disaster response,
recovery and mitigation work. Funding for these efforts should not
compete with first responders, public health, and state and local
emergency managers. So it is essential to fund preparation and response
work through separate sources.
2. Establish a National Center for Excellence in inclusive
Disability and Aging Emergency Management. The initial focus of the
center should include community engagement, leadership, training and
exercise development, evacuation, sheltering, housing, and universal
accessibility. I suggest a budget of $1 billion over 5 years to stand
up the center.
3. Direct the U.S. Department of Justice, and provide the
Department with resources, to monitor and enforce the use of all
disaster funds to ensure compliance with the civil rights requirements
of the Rehabilitation Act of 1973, as amended and the Americans with
Disabilities Act of 1990, as amended.
4. Provide Department of Homeland Security grant funds to
specifically fund qualified and experienced Statewide Access and
Functional Needs Coordinators for all states and territories. These
coordinators would serve as statewide subject matter experts across
preparedness, response, recovery and mitigation to engage and
coordinate whole community collaboration among disability leaders,
community organizations, first responders, emergency managers, public
health and safety, private sector and other stakeholders.
5. Conduct a study of the use of volunteers to determine efficacy
in sheltering services to individuals with disabilities and older
adults. Objectives of the study should include determining if the use
of volunteers is adequate to comply with disability equal access and
6. Refresh the Post Katrina Emergency Management Reform Act to
better define State and Federal Government obligations to plan for,
respond to, recover from, and mitigate all hazards in compliance with
disability civil rights laws.
7. Exempt the cost of disability related repairs and replacement
from the FEMA Individuals and Households maximum grant ceiling
(currently $33,300). Disability related repairs and replacement of
durable medical equipment and other disability items includes replacing
wheelchairs, customized vehicles, medical devices, entrance ramps,
elevator installation to meet home elevation requirements, and other
items that provide equal access for people with disabilities in
recovering from a disaster.
8. Establish an American Independence Corps, similar to FEMA Corps
made up of at least 5,000 citizen members with and without disabilities
to carry out planning and preparation activities in each state, DC and
Territory year round.
9. Direct FEMA and the Administration on Community Living to lead a
coordinated effort across Federal Government agencies, the states,
CBOs, foundations, and other sectors, with those who are aging and
those with disabilities in leadership roles, aimed at achieving on-
going planning, preparation, and implementation of these
Implementing these recommendations will:
Prevent, minimize, and rectify the institutionalization
and/or loss of critical home and community based services for children,
adults and older persons in the lead up to, during or following a
Increase the ready supply of accessible, adaptable,
affordable, and disaster resistant permanent and temporary housing
Let me be very clear, most of the failures and shortfalls we
address are a direct result of the failure to plan at the local and
state level and the failure to place subject matter experts in
leadership roles at every level coupled with failure to include people
with disabilities and older adults as key stakeholders in planning
efforts. This has been coupled with blatant disregard for the
unwaiverable civil rights obligations associated with the expenditure
of every federal dollar spent by government, grantees and contractors
without any monitoring and enforcement by the Federal Government over
its civil rights obligations. To further emphasize this point, there
are no civil rights loopholes releasing anyone from their legal
obligations in emergencies and disasters. Period.
Despite years of planning, people with disabilities and older
adults in Texas, Florida, and the U.S. Virgin Islands, and other
hurricane impacted states have, once again, paid the price for our
collective emergency planning shortfalls. Many thousands are still
without the basic necessities to meet their independence, safety, and
health maintenance needs. Most have been denied their basic right to
equal access to federally funded emergency programs and services. We
receive daily requests to assist people without food and water. Some of
the people calling are in high rise buildings without power. Callers
are unable to obtain prescription medications, return home from
evacuation placement in nursing homes hundreds of miles away, having
extreme difficulty in reaching FEMA and Red Cross to request assistance
and being informed about wait times of up to 30 days for crisis and
immediate assistance funds for food, water and medication.
Effective practices for whole community inclusion must be led by
experts in disability and aging inclusive emergency management. The
people most knowledgeable about the needs in their own community are
best suited to lead disaster response and recovery. We must find a way
for these organizations to have adequate resources to do the complex
and long-term work that is needed for people with disabilities and
older adults to participate with government and the disaster business
giants to get grants, donations, and tax payer dollars to optimize
whole community inclusive disaster recovery.
Portlight Strategies and our national Partnership for Inclusive
Disaster Strategies stand ready to assist the American people to get
Thank you for allowing me this opportunity to share my experience
and recommendations with the Committee and I stand ready to answer any
questions you might have.
Portlight Inclusive Disaster Strategies, Inc. is a nonprofit,
nonpartisan, disability inclusive disaster relief organization
established in Charleston, SC, in 1997. Portlight Strategies does not
receive federal funding.
Portlight Inclusive Disaster Strategies, Inc.
P.O. Box 14109
Charleston, SC 29422
Questions for the Record
To Paul Timmons
From Senator Elizabeth Warren
Climate change is the greatest disaster preparedness and response
issue of our time. A 2016 publication by the Environmental Protection
Agency noted that the consequences of climate changes are serious for
us all, but particularly for older Americans. Additionally, the
nation's population over age 65 is expected to nearly double by 2050,
and approximately 1-in-5 older adults live in an area that was directly
impacted by a hurricane or tropical storm within the last decade.\1\
\1\ Environmental Protection Agency. ``Climate Change and the
Health of Older Americans.'' (May 2016) (https://
As increased flooding, heatwaves, droughts, and other extreme
weather events become more common, does America have the right
preparedness plans in place, or do we need to be doing more to respond
to the needs of seniors and those with disabilities?
Despite the huge investment in preparedness across the country
through the development and implementation of the National Preparedness
System, plans are only in place on paper in most communities. Where
there is actual planning, it generally excludes older adults and people
with disabilities, and where older adults and people with disabilities
are included, the general perspective is that their needs are special
and their contributions are not a key element of a whole community
inclusive approach to universal accessibility and inclusion.
From Senator Marco Rubio
Your testimony emphasizes the importance of including older
Americans when developing emergency response plans.
In your experience, what are some common misunderstandings that you
hear from state and local governments when it comes to meeting the
needs of older Americans after a disaster?
Accessibility is ``nice to have'' not required.
Civil rights and equal access obligations associated with
the use of federal funds can be waived in a disaster.
Older adults and people with disabilities need to be
``planned for'' rather than engaged as knowledgeable partners in whole
Exercises can be effective without using real people with
disabilities and older adults participating.
It isn't necessary to fund accessibility experts and
community organizations. Funding goes to generalists and practitioners
without accessibility expertise, and this is adequate to meet
Older adults and people with disabilities are
``vulnerable'' and their needs are medical, rather than needing
physical accessibility, effective communication accessibility and
program accessibility to maintain health, safety and independence.
Do the residents of nursing homes, assisted living facilities and
others typically have the necessary level of information about how the
facility plans to respond to an emergency?
Residents of nursing homes, assisted living and others rarely have
access to actionable information to plan for, respond to and recover
from emergencies and disasters. This is despite ongoing efforts to
build and implement inclusive planning initiatives locally, statewide
and nationally, and is an example of the deficiencies resulting from
using generalists and medical approaches rather than accessibility and
From Senator Bill Nelson
You emphasized the need for a commission or national infrastructure
to connect and coordinate stakeholders involved in emergency
preparedness. I introduced a bill with Senators Rubio, Casey, and
Collins to create a national advisory commission to advise the
Department of Health and Human Services on disaster preparedness for
seniors. The commission would consist of Federal agency heads, local
agency representatives, and non-Federal emergency healthcare
Why are advisory commissions like the one described above
Disability leaders believe in the adage, ``nothing about us,
without us''. We believe emergency preparedness must be inclusive, this
means planning with us, rather than for us. Advisory boards are a tool
for bringing subject matter experts with lived experience to the table.
We would strongly encourage that the membership of the National
Advisory Council include a majority of older adults and individuals
You spoke at length about the need to promote inclusiveness in
disaster preparedness and response plans for individuals with
disabilities, and I fully agree. In your testimony, you stated that
people with disabilities and older adults are two to four more times
likely to die or be seriously injured in a disaster. In Florida, we are
still in the process of recovering and rebuilding in the wake of
Hurricane Irma. And Puerto Rico and the Virgin Islands are in the midst
of a humanitarian crisis.
What recommendations do you have for Congress, and State and local
governments so that we improve disaster preparedness efforts to better
account for older Americans and people with disabilities?
We strongly recommend monitoring and enforcement of the
Rehabilitation Act requirements in all use of federal funds. Meeting
the obligation to provide physical access, program access and effective
communication access throughout all preparedness, response, recovery
and mitigation activities actually offers a great opportunity to
provide equal access and full inclusion through universal design. This
is smart practice for optimizing limited resources and minimizing
unnecessary use of medical and responder resources simply because of a
lack of inclusive planning.
It's time to directly fund local independent living centers and
disability organizations. These are the experts on housing, health
care, transportation and benefits navigation needs of older adults and
people with disabilities. During and after disasters, they usually end
up providing the services that the funded organizations are unfamiliar
with. However, they are not funded and the impact on their resources
limits services to both disaster survivors and individuals not impacted
by the disaster.
Finally, training and technical assistance in achieving and
maintaining disability inclusive whole community readiness and
resilience must be led by experts. Too many amateurs are using unproven
practices, and failing to establish objectives or measure results. We
strongly recommend the establishment of a National Center of Excellence
in Whole Community Inclusive Emergency Management.
Prepared Statement of Jay Delaney, Fire Chief and Emergency Management
Coordinator, City of Wilkes-Barre, Pennsylvania
Chairman Collins, Ranking Member Casey, and members of the U.S.
Senate Special Committee on Aging, thank you for inviting me here today
to discuss how cities and towns across the country can help ensure the
health, safety, and resilience of older Americans and individuals with
disabilities during and after disasters.
I am the Fire Chief for the city of Wilkes-Barre, Pennsylvania. I
have been honored to serve the city in this role for over 12 years and
a total of 36 years in Emergency Services. I am also the Emergency
Management Coordinator for the city of Wilkes-Barre and a certified
Over 40,000 people reside in Wilkes-Barre, a city located in
Luzerne County. Nearly 19 percent of the county's residents are over
age 65, which is three percent higher than the average for the state.
And, many of the older residents are concentrated within the city
Like any Fire Chief or Emergency Management Coordinator, I feel a
great sense of responsibility for these older Pennsylvanians; many who
live by themselves.
My concern for their well-being is heightened whenever there is a
threat of a severe storm or weather event.
That is due to a 10,000 square mile watershed that drains into
Wilkes-Barre from Susquehanna River, threatening to flood our streets
In August 2011 the threat became very real as the east coast braced
for Hurricane Irene and Lee to make landfall. What transpired over that
next week explains why early weather tracking, data, surveillance and
the flow of information across all levels of government is a priority
and critical to the health and safety of residents.
About seven days before the storms were scheduled to hit, we heard
from the National Weather Service. They started to send us regular
updates about the storm patterns and possible rainfall and potential
crests for the Susquehanna River. The Pennsylvania Emergency Management
Agency disseminated critical data to the County Emergency Management
Officials and the emergency management coordinator for each
Wilkes-Barre is protected by a U.S. Army Corp of Engineers levee to
a river level of approximately 42 feet. The Susquehanna River crested
on September 9, 2011 at a record and historic level of 42.66 feet.
For years, the gauges that measured the water height of Susquehanna
River in Wilkes-Barre were broken and were the responsibility of the
U.S. Geological Survey. Senator Casey led the charge here in Washington
to secure the resources to replace our broken gauges. It is because of
Senator Casey that we can track--in real time--the possibility of a
flood and critical river level data. This type of surveillance
information provided the needed data to make risked based decisions for
Using maps of flooding that took place in 1972 after Hurricane
Agnes, we created an evacuation zone. And, on September 9, 2011, we
successfully evacuated 15,000 residents of Wilkes-Barre in about 10
hours. This evacuation included Wilkes-Barre City Hall, Wilkes-Barre
Police Headquarters and Wilkes-Barre Fire Headquarters as well as the
entire downtown, King's College and Wilkes University.
We alerted the local hospital and the two nursing homes in the
evacuation zone. They executed their Emergency Preparedness Plans and
safely evacuated over 250 seniors. And, if at any time, they thought
that they were going to have trouble evacuating in the time required,
they knew to request additional help from the Wilkes-Barre City
Emergency Operation Center. We would send ambulances and personnel to
But, it was the older Pennsylvanians, the seniors, and those with
disabilities who still lived in their homes and in the community that I
worried about most--the Mr. and Mrs. Smiths who have lived in their
home for 50 years.
In preparation for a possible evacuation, we had developed a grid
designating areas of responsibility for Fire Department, the Police
Department and members of the National Guard.
We drove through South Wilkes-Barre and the downtown making
announcements from our vehicles, knocking on doors, and posting
evacuation orders. We knocked on every door. We left notes on doors of
the homes where no one answered and made an additional check to ensure
their evacuation. Most people heeded the request to evacuate on the
first try, but if anyone resisted, they took their names and wrote down
their addresses and we spent additional time working to get them out of
We successfully executed our plan because of the seamless
collaboration and communication among officials at the national, state,
and local levels.
But, even so, after every major event, we look back and discuss how
we can improve. For example, should we ever need to evacuate again, we
now have a contact in place with a local bus company that agreed to
drive routes throughout the city to pick people up and take them to
Following Hurricanes Harvey and Irma, I hope that Congress will
conduct its own after action review as it did after Hurricane Katrina
in August 2005.
While Presidential Directive 5 started the advancement of the
National Incident Management System it was for the most part put into
action after Hurricane Katrina and is a model for how all levels of
government manage all types of emergencies and disasters. As part of
that review, I hope that Congress will commit to continue to fully fund
the National Weather Service and FEMA, and invest surveillance tools so
that we have the most comprehensive information available before,
during and after a disaster to guide our decision-making. Without early
weather surveillance we have little time to plan and prepare for
potential weather events.
I am grateful to the Senate Special Committee on Aging for the
opportunity to add my voice to this conversation.
Additional Statements for the Record
Statement of Senator Marco Rubio
I would like to thank our witnesses for their time and willingness
to testify before the Senate Aging Committee, and I wanted thank Dr.
Kathryn Hyer in particular for making the trip from my home State of
Florida. The topic of disaster response for older Americans is
especially important for states, like Florida, with a large senior
population, and I thank you for your work.
In the wake of a natural disaster, we can be painfully forced to
grapple with our own shortcomings and failure to prepare for all
scenarios. In the aftermath of Hurricane Irma, 11 senior citizens
senselessly died in Hollywood, Florida. The victims in this particular
case were later found to have body temperatures far above safe levels,
some reaching nearly 110 degrees. According to the CDC, temperatures
over 103 degrees puts people at risk of a heat stroke and that senior
citizens are more vulnerable to high temperatures.
My own mother is in an assisted living facility and I cannot
imagine the pain that these victims' families must be dealing with.
I am committed to working with my colleagues to fill the gaps in
our current emergency response system, starting with legislation that
Senator Bill Nelson and I introduced that would establish an Advisory
Council on Seniors and Disaster. This legislation would require the
heads of multiple federal agencies to assess the specific needs of
seniors, our nation's current capacity to quickly meet those needs
after a disaster, and work with state governments to ensure they have
the necessary tools and capabilities to care for older Americans in the
wake of a disaster.
This advisory committee is only part of the solution, and I look
forward to learning from our witnesses about other ways to fix this
Statement of Katie Smith Sloan, President and CEO, LeadingAge
LeadingAge appreciates this opportunity to comment on the need to
improve planning, preparation and protection for vulnerable populations
threatened by disasters such as the recent hurricanes in Texas and
Florida. We commend the Committee's efforts to ensure the safety of
America's older adults in emergency situations.
The mission of LeadingAge is to be the trusted voice for aging. Our
6,000+ members and partners include not-for-profit organizations
representing the entire field of aging services, 38 state associations,
hundreds of businesses, consumer groups, foundations and research
centers. LeadingAge is also a part of the Global Ageing Network, whose
membership spans 30 countries. LeadingAge is a tax-exempt charitable
organization focused on education, advocacy and applied research.
Vulnerable older adults must be protected in the event of disaster.
This effort must involve collaboration between public and private
agencies. Not only must older adults be kept safe during events like a
severe storm or other natural disaster, but they often need assistance
in the aftermath with services like food, fresh water, and electricity
to power essential medical equipment.
We support a three-pronged approach to emergency preparedness on
behalf of older adults:
A Federal regulation that will be effective November 15
will require certain providers of health care and long-term services
and supports to have plans for foreseeable natural and man-made
Senators Bill Nelson, Marco Rubio, Bob Casey, and Susan
Collins have introduced the Protecting Seniors During Disasters Act,
which will establish a National Advisory Committee on preparing seniors
for an emergency.
Federal, state, tribal, regional and local emergency
preparedness authorities must recognize the special needs of older
adults and put this population and the organizations that serve them on
priority lists for restoration of essential services.
Emergency Preparedness Final Rule
On September 8, 2016 the Centers for Medicare and Medicaid Services
(CMS) posted a final rule, Emergency Preparedness Requirements for
Medicare and Medicaid Participating Providers and Suppliers. The rule
becomes effective on November 15, 2017.
The rule applies to all health care providers that participate in
Medicare and Medicaid, including hospitals, nursing homes, hospice and
home care agencies. Having an emergency preparedness plan in place will
be a requirement or condition of participation in Medicare and Medicaid
for all providers. The inspection or ``survey'' that nursing homes
undergo annually will include a review of the nursing home's emergency
To implement the new requirement, providers are to take an ``all
hazards'' approach, assessing the organization's vulnerability to
natural and man-made disasters. The kinds of disasters for which
providers must plan include emergencies related to patient care; loss
of water or other utilities; loss of part of the facility, equipment
failures, communication breakdowns, unavailability of food and
medication shipments, and similar emergencies. Emergency preparedness
plans must take into account the special needs of the populations the
provider serves, such as limited mobility, dependence on medical
Providers must develop policies and procedures to protect residents
and patients in the event of potential disasters, train their staff in
these procedures, and regularly test the adequacy of the procedures.
Staff training must include exercises conducted among senior staff in
an organization and full-organization drills involving the entire
staff. CMS guidance issued on the final rule includes consideration of
evacuation plans and back-up evacuation plans in the event that the
planned destination becomes inaccessible or is unable to accept more
The guidance notes that mobility can be an issue for many at-risk
populations, including older adults and persons with disabilities.
Emergency preparedness plans must ensure that transportation is
available and that staff responsible for transporting older persons
know the procedures to be followed. Alternative facilities that could
be destinations for evacuated patients and residents will have to be
identified, along with the financial resources that will be necessary
to carry out the plan.
Issues of potential leadership succession must be addressed in
emergency plans, ensuring that personnel are available to fill critical
decision-making roles. Plans also must include protection of vital
records and health information technology.
An important aspect of the emergency preparedness rule requires
coordination and collaboration with public authorities in charge of
emergency response. To comply with the new rule, providers will be
required to document the ways in which they have collaborated with
these public authorities in the development of their emergency
Since the final rule was issued last year, LeadingAge and its state
partners have published and disseminated information for our member
nursing homes, home care and hospice providers on developing and
implementing the required emergency preparedness plans. We also have
conducted numerous education sessions for our members, both in person
and electronically. We will continue doing everything possible to
ensure our members' successful compliance with the new requirement. And
we urge the Special Committee to take the new rule into account in
considering what action is needed to make sure that older adults are
protected in the event of disasters.
Protecting Seniors During Disasters Act
LeadingAge commends Senators Bill Nelson, Marco Rubio, Bob Casey,
and Susan Collins for their introduction of this legislation, which
will establish a National Advisory Committee on Seniors and Disasters.
This kind of committee could encourage better coordination and
collaboration among the various public and private entities responsible
for proactive steps to ensure older adults' safety.
We are pleased to see that a wide range of federal officials and
agencies is to be represented on the Advisory Committee. We would
recommend, in addition, that a representative from the Department of
Housing and Urban Development (HUD) be added to the commission.
Residents of public senior housing communities are especially
vulnerable to damage to their homes and interruptions in their supply
of food, water, and essential medications as a result of natural
disasters. All too often following a disaster, we see that older adults
with high needs living independently in their communities are not given
priority by public authorities for emergency supplies of food, water
and essential services.
As an example of the kind of services needed by older adults living
in the community, in mid-September LeadingAge and our member National
Church Residences established the Hurricane Services for Seniors
hotline. National Church Residences serves as a clearinghouse, matching
needs for housing and services with older adults affected throughout
Texas, Florida, and Puerto Rico. The hotline shares resources and
connects callers with available housing. Service coordinators help
guide the older adults through the steps of filing for federal and
state assistance. The hotline is an example of a service that could be
expanded through collaboration with the Administration on Community
Living at HHS and HUD using a network of specially trained HUD-housing
While their needs may be addressed to some extent by home health
care agencies or other health care providers under the final rule
discussed above, we are concerned that these older adults could fall
through the cracks of public and private emergency preparedness plans.
It is not just their medical and health care needs that must be
addressed; restoring access to food and water is of critical
importance. We therefore urge that an official responsible for senior
housing programs within HUD be added to the advisory committee.
Older Adults Must Be Given Priority Status in Public Preparedness
As discussed above, the final rule on emergency preparedness
requires health care providers to document their efforts to work with
public emergency and disaster preparedness authorities on plans to
ensure older adults' safety.
As our member organizations have worked on developing their plans,
unfortunately they do not always have the cooperation of public
authorities in their regions. In some areas, authorities apparently
believe it is sufficient to give priority to the local hospital for
restoring water and other utilities but not long-term care and senior
A broader view of priorities will be essential if the needs of
older persons in emergencies are to be met. We urge the committee to
use its influence with state and local authorities to make them aware
of the importance of including all providers of services to older
adults in their plans for responding to emergencies and disasters.
LeadingAge commends the Committee for its attention to this
critical issue and we look forward to working with you to ensure the
safety of older persons during and after disaster strikes.
Statement of James R. Balda, President and CEO, Argentum
On behalf of Argentum, which advocates for excellence in senior
living, we thank you for holding a hearing on the important topic of
the special needs of older Americans when it comes to disaster
preparedness and response. This population is one of the nation's most
valuable resources, but also one of the most vulnerable.
Argentum is the leading national association exclusively dedicated
to supporting companies operating professionally managed, resident-
centered senior living communities and the older adults and families
they serve. Argentum member companies operate senior living communities
offering assisted living, independent living, continuing care, and
memory care services to older adults and their families. Since 1990,
Argentum has advocated for choice, independence, dignity, and quality
of life for all seniors.
Argentum has worked with the senior living industry in all states
to advance industry standards and regulations to ensure that all senior
living communities continue to provide high quality care and quality of
life as well as appropriate supports and services to the diverse array
of residents served, including effectively preparing for the
inevitability of natural disasters.
Caring for a population that includes frail seniors in the face of
a natural disaster offers many challenges, such as safe transportation;
providing appropriate health services and nutrition; meeting the needs
of people with special conditions such as dementia, limited ambulation,
and vision or hearing impairments; ensuring there is access to medical
records and life-saving medicines; emotional issues such as separation
from loved ones and caregivers; vulnerabilities to those who prey on
older adults through elder abuse; and other risks related to
As you know, the senior living industry is regulated in every state
and must follow the relevant state laws, regulations, and codes to
ensure the safety of community residents. States that are the most
successful in integrating the needs of seniors in their emergency
preparedness plans are those that offer clear, collaborative efforts
between their emergency management and health agencies, and long-term
care providers. Advanced planning, prevention, communication, and state
and local partnerships are critical in helping to ensure the safety and
well-being of older adults, especially those who are vulnerable in a
disaster or emergency. Assisted living communities in each state are
required to have an emergency management plan in place to rely on
during a dynamic environment such as a natural disaster.
We were heartened to hear that the nearly 190,000 residents and
patients served in long-term care communities in Florida remained safe
thanks to the smart planning of long-term care employees in preparing
communities to cope with an emergency situation such as a natural
For example, Legend Senior Living based in Wichita, Kansas, owns
and operates eight Florida-based senior living and memory care
communities, which house more than 640 residents and employ more than
540 people across the state. A 24-hour command center was immediately
organized at the home office in Wichita. Generators were tested and
prepared for use. Nursing staff ensured that sufficient medication was
in stock. Residence directors communicated with neighboring fire
departments and hospitals to discuss possible emergency situations. The
home office had calls with each community every four hours to ensure
they were equipped and safe. When electricity went out, the phone
system rolled to Wichita. The Florida communities worked hard to
alleviate resident unease and were fortunate to have a chef who could
continue to prepare meals and popcorn for residents to enjoy while
watching football on television.
Other providers that needed to evacuate residents sent them to
sister communities nearby or in some cases companies rented out entire
hotels to move in residents, staff, and their families. The widespread
nature of these two disasters brought out the best in senior living
providers. In Texas, memory care specialist Silverado took in 30
patients from a hospital that needed to evacuate. Providers opened
their doors to residents from nearby cities and towns who arrived wet
and cold and were given warm clothes, food, and a place to stay.
Every emergency situation is different. At some point, a decision
must be made on whether to shelter in place or evacuate. It's not an
exact science and as was demonstrated in Florida, hurricane paths can
swiftly change. In Texas, the Dickinson-based community that received
negative national attention was told to shelter in place by the city's
mayor. At some point, that decision did need to be reversed when the
rising waters filled the community. Thankfully, everyone was safely
Professionally managed senior living communities are structured to
cope with the distinct needs that older adults pose in the face of
natural disaster. Each stage of an emergency, whether sheltering in
place or evacuation, must be treated differently when dealing with
frailer adults than other populations. Community staff understand the
custom care plans that an older adult may not be able to experience
from a shelter or relief organization unfamiliar with a frail
Some valuable lessons were learned from Hurricane Katrina resulting
in much better care in a natural disaster emergency. During the recent
hurricanes in Florida and Texas, wrist bands with names and community
were immediately placed on resident wrists along with medication
identification. Families were notified where their loved ones would be
taken in case of evacuation.
We have all learned from past tragedies, and Argentum currently is
in discussions with Florida and Texas officials about regulations that
have proved effective. For example, Texas in 2011 passed a law
prioritizing assisted living communities for restoration of electricity
following an extended power outage. Assisted living is not on such a
priority list in Florida. We must have thoughtful discussion about the
role for generators, adequate fuel supply, and safety considerations
such as significant fuel storage on the site of a caregiving community.
Several of our member companies were unable to access fuel to power
their community generators and buses post-Hurricane Irma and searched
for gas as far away as Maryland and Tennessee.
We also hope this situation spurs a discussion about a need to
consider in the future possible alternative energy sources and
technology uses that could help long-term care organizations navigate
this issue successfully.
Natural disasters are inevitable and can occur anywhere, at any
time, in the United States. Argentum and its members have worked hard
to elevate the importance of disaster preparedness. We take it very
seriously. The lives of each and every resident is precious and let's
not forget the caregivers who were the real heroes during these storms.
They spent night after night in the senior living communities caring
for residents and many were not able to be with their own families
during this time. While the safety of the senior living residents took
priority, many caregivers finally went home to realize they had lost
everything. Many companies in Texas and Florida have been fundraising
with company matching programs to help these employees get back on
their feet. Argentum has pledged to match up to $50,000 in donations
from the senior living industry to communities and employees negatively
affected by Hurricane Harvey. Please see the Addendum that follows
which highlights just a few of the many stories we received of
compassionate care, heroism, and acts of kindness from residents,
families members of residents, and staff members from communities
across the states affected by the hurricanes.
We look forward to continuing our dialog with you to ensure that
all of our nation's seniors are housed safely at all times in a caring,
nurturing environment. Argentum is available to further address any of
We sincerely appreciate your consideration of these comments.
Preparing and Caring in the Face of a Natural Disaster
Senior Living Prioritizes Resident Safety and Comfort
Caring for Residents, Staff, and Community
Below are a sampling of the many letters of appreciation and
support that have poured in from family members following the recent
hurricanes in Texas and Florida:
Family Member of Belmont Village Resident (Texas): First I want to
say I felt that you all handled the lock-down for the residents of
Belmont Village Hunters Creek during Hurricane Harvey really well. I
appreciate the e-mail updates and the 800 call-in number to stay up to
date of daily on goings. I had complete peace of mind that my parents
were well-cared for, busy, and kept in their normal routine during that
stressful time. Also I don't think they had much understanding of what
was going on outside the walls of the building, all over the city of
Houston. So they were not frightened, for which I was very thankful. A
heartfelt thank you goes out to you all.
After Hurricane Harvey, Atria Senior Living held a Texas-Sized
Feast at the Support Center--as did many of its communities across the
country--to raise funds for Atria Cares and affected employees. So far,
more than $200,000 has been raised.
Family Member of Atria Evergreen Woods Residents (Florida): The
most precious people in my life are those that raised me as a child.
With many others in Florida and as Atria Evergreen Woods residents,
they were confronted with the path of hurricane Irma in September 2017.
While many citizens of Florida were struggling with the idea of
evacuations, Atria had everything planned and under control. You moved
your Atria residents to a location in Orlando. The fact that Atria had
a preplan and a hurricane safe location ready was extremely re-assuring
for me and my family. The larger success story comes with the level of
service, support and care that the Atria employees gave to its
residents in the Orlando location during and after the hurricane. My
aunt and uncle raised me from very young and they mean everything to
me. Living in New York, you can imagine how difficult it was for me to
deal with the situation. The feedback I would like to give you, which I
hope is cascaded to the service providers, is that they were given
first class attention and service during this natural disaster.
Medication Tech, Autumn Leaves of Estero (Florida): It was the most
humbling experience I have ever had. This storm made me appreciate a
lot of things and look at life differently. Autumn Leaves opened their
doors to my family in order to keep them safe and us together. They
opened their doors to help others affected by the pending storm. They
kept all of us safe and free from harm. I would not change anything and
would do it all over again to care for our residents and families!
Retirement Management Center was able to give shelter to two senior
brothers, who were neighbors from across the street.
Retirement Center Management (Texas): On Sunday, August 27 around
3 p.m., the community received a call from the nephew of Chris and
Johnny, brothers who live across the street from a Retirement Center
Management community. One is diabetic and the other is an amputee with
a prosthetic leg. A person kayaking down the street was asked by the
community staff to assist Chris across the street. The staff was
concerned about him walking in the water since he had some open sores
and is diabetic. The community nurses did an assessment when the
brothers arrived at the building and were able to provide them shelter
from the storm with a warm location, dry clothes, and food and water.
The community served as an emergency storm shelter for more than 10
people during the severe flooding.
The Fountains at Boca Ciega Bay in St. Petersburg (Florida):
Located right on the Bay, this community was ordered to evacuate two
days before Irma hit. The task was nothing short of monumental, but
every Watermark community has a custom, detailed Emergency Preparedness
Plan and the Fountains at Boca Ciega Bay followed each step for a
successful evacuation and return. Details range from ``unplug computers
and appliances'' to ``arrange for pharmacy and follow all medical
charts'' and ``coordinate buses with chair lifts and bathrooms'' plus
everything in between. Residents of our independent neighborhood
evacuated to the Mission Inn, a resort hotel an hour or two from the
community. Temporary housing in a big ballroom provided a safe
experience and the hotel staff worked tirelessly alongside our
associates to ensure a positive experience. Residents played games and
cards thanks to quick thinking community life associates who grabbed
them all on the way out. Exercise programs, club meetings and classes
were held with enthusiasm to keep the days fun and to offer residents a
routine as close to our typical lifestyle as possible. One resident
brought her harmonica and entertained folks during and after the storm,
with sing-a-longs of everyone's favorites.
Resident at Five Star Senior Living, Horizon: The staff was
absolutely wonderful during this hurricane. Many stayed here to assist
and the attitude was one of what can we do to help--friendly, smiling,
eager to please--which combined with older people already upset and
sometimes confused, was a real positive attribute in these
circumstances. The nurse remained on duty the entire time checking in
on every resident who might have needed her aid. Our Director was here
full time during the hurricane, as were several of the sales staff and
Resident at Brookdale First Colony (Texas): During the weeks and
days that Harvey waged his ``war'' on our State, I was moved by the
care and love which emanated from Brookdale First Colony staff who
remained with us during the deluge. They calmed our nerves, welcomed
our displaced relatives with open arms and were deeply concerned for
all. They say heroes are made in times of war. These associates were
our heroes and deserve Medals of Honor.
Uniting and Rebuilding
Many senior living companies quickly rallied resources to ensure
staff and communities negatively affected by these natural disasters
were taken care of. Here is a sampling of their efforts:
Watercrest Senior Living Group of Vero Beach, Florida is
spearheading a $100,000 fundraising initiative coined `Watercrest
CARES' in support of Samaritan's Purse for Hurricane Harvey disaster
relief. Samaritan's Purse is a Christian organization led by Franklin
Graham, son of Billy Graham, serving victims of disaster worldwide.
Watercrest principals, Marc Vorkapich, CEO and Joan Williams, CFO,
launched the `Watercrest CARES' fundraising campaign with a starting
donation of $10,000, encouraging others to contribute to the campaign's
Sunrise Senior Living community The Fairfax held a ``fill the
truck'' fundraiser on September 21 to benefit those affected by Harvey
and Irma. The Army Retirement Foundation-Potomac, a 501c3 charitable
organization that founded The Fairfax Military Retirement Community
near Fort Belvoir, VA, is also managed by Sunrise Senior Living. Co-
hosted along with TAD Relocation (TAD relocation assists in planning
and downsizing of residents moving into The Fairfax and other senior
living communities), a Fill a Truck event was held today to collect
items by those affected by Hurricane Harvey. They filled the entire
truck (a 26 foot moving truck!) with donations of clothing, bedding,
hygiene and personal care products, children's toys, furniture, food,
kitchen items, and pet items.
Legend Senior Living based in Wichita, Kansas, with communities in
Florida, set up a $20,000 fund for associates impacted by the storm,
and other Legend associates gave another $5,000 to it. It is helping
associates who have flooded homes, cars, and the many who lost power
who had to re-stock the refrigerator. The company housed all our
associates 24-7 who worked during the hurricane's passing as well as
their families. They said they felt safer in the Legend building than
Belmont Village financial contributions to the company's relief
fund, BVCares, now total $106,000 including the company match, creating
a source of critical support funds to help Belmont's staff recover from
damage to home and property.
Atria Senior Living raised over $200,000 for their Atria Cares, an
employee-funded nonprofit organization that provides emergency
financial assistance to Atria staff in need.
Best Practices and Lessons Learned
The senior living industry has applied its knowledge gained over
the decades of caring for older adults, including best practices
gleaned from coping with natural disasters. Here are some of the
highlights from lessons learned that made senior living able to
successfully navigate many of the challenges presented by hurricanes
Harvey and Irma.
1. The decision of whether to evacuate or shelter in place is a
complicated process that requires a complete and thorough assessment of
the situation. Both options have advantages and challenges. But
assisted living providers are prepared for both through the development
of emergency disaster management plans. State rules require that
communities have food, water, and other necessary supplies for
emergency situations that require sheltering in place. Plans also need
to specify procedures for evacuations.
2. In addition to well thought out emergency plans, regularly
scheduled drills involving team members and residents is critical to
the successful implementation of the plans.
3. States that are the most successful in integrating the needs of
seniors in their emergency preparedness plans are those that offer
clear, collaborative efforts between their emergency management and
health agencies, and long-term care providers.
4. Advance planning, prevention, communication, and state and local
partnerships are critical in helping to ensure the safety and well-
being of older adults, especially those who are vulnerable in a
disaster or emergency.
5. Companies with a headquarters outside of the affected zone can
take on many of the administrative and coordination responsibilities to
free up staff to care for residents. For example, Legend Senior Living
based in Wichita, Kansas, owns and operates eight Florida-based senior
living and memory care communities, which house more than 640 residents
and employ more than 540 people across the state. A 24-hour command
center was immediately organized at the home office in Wichita. The
home office had calls with each community every 4 hours to ensure they
were equipped and safe. When electricity went out, the phone system
rolled to Wichita.
6. Other providers that needed to evacuate residents sent them to
sister communities nearby or in some cases companies rented out entire
hotels to move in residents, staff, and their families
7. Providers opened their doors to residents from nearby cities and
towns who arrived wet and cold and were given warm clothes, food, and a
place to stay. In Texas, memory care specialist Silverado took in 30
patients from a hospital that needed to evacuate. In at least one
example, the assisted living community took in elderly living alone in
their own homes who did not have the supplies necessary to survive the
8. Many lessons were learned from Katrina. For example, during the
recent hurricanes in Florida and Texas, wrist bands with names and
community were immediately placed on resident wrists along with
medication identification. Families were notified where their loved
ones would be taken in case of evacuation.
9. Autumn Leaves offered real-time updates on Web sites during each
of the recent hurricanes for friends and family to get up to the minute
information on their affected communities.
10. Argentum is establishing an Emergency Preparedness Standards
Board to develop assessment tools, sample plans and training to senior
living providers in the emergency preparedness efforts.
Statement of Teresa Osborne, Pennsylvania Secretary of Aging, and Rick
Flinn, Director, Pennsylvania Emergency Management Agency
Chairman Collins, Ranking Member Casey, and Members of the
Committee, thank you for holding a hearing to examine disaster
preparedness and response for older Americans.
September is National Preparedness Month and this year's theme is,
``Disasters Don't Plan Ahead. You Can.'' Recognizing that we are in the
immediate aftermath of Hurricane Harvey and Hurricane Irma, disasters
like these serve as a reminder that each of us must be prepared for
emergencies that can easily affect us where we live, work, or visit.
Being prepared for the next potential emergency is a top priority
for the Wolf Administration. As such, the Pennsylvania Emergency
Management Agency (PEMA) and the Department of Aging have been engaged
in conversations about emergency preparedness and Pennsylvania's older
population. A recent survey conducted by PEMA revealed that only 26% of
Pennsylvanians age 65 and older have a plan in place for when disaster
strikes. This sobering statistic tells us that we all have friends,
family, neighbors, and consumers who have no plan for how to act when a
disaster is imminent, don't know how to respond after one has struck,
and may not know how to communicate if they need assistance.
Older Pennsylvanians have some of the same needs as the general
population during a human-made or natural disaster. However, for older
adults and persons with disabilities, they may also have a wider
variety of functional limitations and some additional challenges to
consider, including medical equipment, accessibility and transportation
issues, and access to prescription medications. Approximately half of
those over age 65 have two or more chronic health problems, such as
heart disease, diabetes, and Alzheimer's disease. These conditions
increase a person's vulnerability during periods of time without food,
water, shelter, and adequate rest. According to the 2010 U.S. Census,
of the older adults who were living outside nursing homes or hospitals,
nearly one third (11.3 million) lived alone. This reality makes the
creation and maintenance of a support network particularly important.
Because emergencies and disasters strike quickly, you might be
forced to evacuate your neighborhood or be prepared to be confined to
your home. While first responders and relief workers will quickly be on
the scene, they may not be able to reach everyone immediately, meaning
that help may arrive in hours or even days depending on the extent of
damage. What would you do if your basic services: water, gas,
electricity, or communications, were cutoff? Even if you have physical
limitations, you can still learn how to protect yourself and cope with
disaster by planning in advance and by working with those in your
support network: your family, neighbors, friends, and caregivers, as
well as your local responders as a team.
During September, the month dedicated to emergency preparedness, we
are encouraging all older Pennsylvanians and their families to be
informed, prepared, involved and ready. We are sharing three easy steps
that they can take:
1. Visit www.ready.PA.gov to take the ``Ready PA Preparedness
2. Download the ``Get Ready Now'' pocket guide, a 3-step guide on
emergency preparedness for older adults. To access the guide, go to
www.aging.pa.gov, hover your mouse over the ``Publications & Reports''
dropdown, then click on ``Emergency Preparedness'' (Direct link:
3. Call your local Area Agency on Aging (AAA), which is poised to
participate on every level of emergency preparedness planning, and meet
the needs of the communities they serve in times of crisis. Find your
local AAA at www.aging.pa.gov/AAA
We are sharing these steps with the Committee to the extent that
they can be used as a model for other States, in taking extra
precaution in preparing for a disaster. Pennsylvania will continue to
be a leader in the area of preparedness and response, and we look
forward to working with the Committee to ensure older adults across the
Commonwealth and country are prepared for the possibility of a