The federal government is re-examining its emergency preparedness requirements for nursing homes after the deaths of 15 Louisiana residents who were evacuated during Hurricane Ida to a crowded warehouse later deemed by the state to be unsafe and unsanitary.
The evacuation revealed weaknesses in the oversight of long-term care facilities in Louisiana and nationwide, according to advocates for the elderly, as well as officials and political leaders, who warned that regulatory shortfalls will continue to endanger vulnerable residents as extreme weather grows more common.
“It is unacceptable for nursing home residents to be put in unsafe situations,” Chiquita Brooks-LaSure, administrator for the Centers for Medicare and Medicaid Services, said in a statement to NBC News.
The agency is now evaluating the federal requirements for emergency preparedness and the oversight process, which is led by states.
“Our priority is to hold nursing homes accountable and protect nursing home residents and staff at all times — including during emergencies,” Brooks-LaSure said.
As Ida approached the Louisiana coast last month, seven nursing homes owned by real estate developer Bob Dean evacuated nearly 850 residents into a warehouse in Independence, about an hour north of New Orleans, that Dean also owned.
Some elderly residents in the overcrowded facility were forced to sleep on wet mattresses as the facility flooded, and they were not provided adequate food or access to toilets, according to multiple lawsuits and reports publicly posted by state health inspectors. Health inspectors described residents crying for help, with no staff answering, and sitting in soiled diapers, with a strong stench of urine and feces throughout the building.
So far, out of the 15 residents evacuated to the Louisiana warehouse who died as of last week, five deaths have been confirmed to be “storm-related,” according to Mindy Faciane, a spokeswoman for the Louisiana Department of Health. Eight additional residents remain hospitalized.
All seven facilities had submitted documents to state authorities detailing their plans to evacuate to the warehouse and other emergency procedures.
But under existing state and federal policies, those plans were only subject to a limited review by state officials to verify whether they contained all the required elements. State authorities say that officials are not required to approve the plans under state or federal law. Local officials must receive a copy of the plans but also do not approve them.
And Louisiana does not restrict the types of building that nursing homes can use for evacuation sites to residential structures like hotels, so there was no rule preventing the use of a warehouse.
“What's the purpose of a mandated plan that can say anything, apparently, if nobody has to approve it?” state Rep. Tony Bacala, a Republican from the Baton Rouge area, said Friday at a heated oversight hearing of the state Legislature. “All that you are getting is boxes that are checked and numbers that are put into blanks.”
Most of the state requirements involve self-reported answers to questions, with “no review, no audit to ensure that these are the correct answers,” he added in a later interview.
After Hurricane Katrina in 2005, both Louisiana and the federal government put stricter rules into effect requiring all nursing homes to have detailed emergency plans, including procedures for sheltering in place and evacuation — an event that can be highly dangerous for frail, older residents, many with significant medical needs.
But what happened in the warehouse during Hurricane Ida shows the urgent need for significant changes to state and federal policies, advocates and officials said.
“These folks should never have been brought into a warehouse to begin with at all,” said Ronald Haley, an attorney representing an evacuated nursing home resident who is suing Dean and the Louisiana Department of Health for negligence. He accused state officials of “passing the buck” by denying they had ever approved the emergency plans.
“If you reviewed it and saw they were going to dump 800 people into a warehouse, how come you didn’t do anything to stop it?” Haley said.
State officials declined to say whether they had found any deficiencies or shortcomings in those plans, directing NBC News to file a public records request. The department has yet to respond to that request.
Through his attorney, John McLindon, Dean declined to be interviewed. McLindon said the Louisiana Department of Health never raised any objections to the plans.
“It was approved, and the building was approved,” McLindon said. “No one from LDH had a problem with that building.”
McLindon defended the evacuation plan and called the criticism “Monday morning quarterbacking.” He said he did not believe the deaths were caused by the storm or the evacuation.
While Dean’s nursing homes have received low performance ratings from the federal government — six out of seven facilities were rated one star out of five — federal inspections of Dean’s facilities found no deficiencies in emergency planning within the last three inspections, records show. (McLindon said the poor ratings did not reflect the quality of the homes, but the fact that the facilities served low-income patients.)
The shortcomings in emergency planning are only becoming more concerning in the wake of climate change, said Lori Smetanka, executive director of the National Consumer Voice for Quality Long-Term Care, an advocacy group for nursing home residents.
“We are seeing increasingly examples of weather situations and disasters — it does raise the urgency to ensure that all of the facilities have plans that are workable and operational and can protect the residents,” Smetanka said. “People are dying as a result of facilities not being prepared.”
During Hurricane Katrina and its aftermath, at least 132 nursing home residents died from various causes, including drowning and evacuation, raising alarms about the need for better emergency planning. In the wake of Hurricane Irma in 2017, 12 residents died in a Florida nursing home from heat exposure after air conditioners failed, leading to criminal indictments. The same year, Hurricane Harvey sent 12 inches of rank floodwaters sloshing through a Beaumont, Texas, nursing home that had failed to evacuate.
Such disasters have prompted changes in both state and federal rules to ensure that nursing home residents are better protected, especially as nearly half live in hurricane-prone Gulf and Atlantic states, according to a 2006 study.
But state inspectors — who are responsible for carrying out both state and federal oversight of emergency plans for nursing homes — have limited authority, even in Louisiana, where the requirements are stronger than in most other states.
Under Louisiana law, officials are only required to determine if a facility’s summary of its plan “contains the required elements” in a 12-item checklist, such as a current list of staff contact information, a signed agreement with the evacuation host facility and transportation arrangements, state health officials told NBC News in response to a public records request.
Louisiana’s health department says it “reviews” the emergency plans to see if they have the elements required; it does not formally approve them or assess them in greater detail.
During Friday’s hearing in the Louisiana Legislature, the state health department declined to answer specific questions from lawmakers about its review of emergency plans for Dean’s facilities, citing the ongoing litigation. In a statement to NBC News, the department described the warehouse conditions as “reprehensible” and said it was committed to discussing next steps after an internal review of the event.
“We know families are hurting and are angry, and we know Louisianans have questions. We do too,” the health department said.
Federal and local oversight of emergency planning is even less stringent.
Under post-Katrina federal rules enacted in 2017, all nursing homes are required to create more detailed emergency plans describing procedures for both sheltering in place and evacuations, including staff training, tests and drills, which are evaluated during routine inspections conducted by state surveyors. But while facilities must “develop arrangements” for alternative care sites and transportation in the event of an evacuation, they are not required to have contracts with specific host sites or companies; verified agreements or contracts are mandatory under Louisiana law.
Louisiana also requires nursing homes to submit their emergency plans to local officials and address any concerns they raise. But local governments are not required to vet the plans or give feedback. LaFourche and Terrebonne parishes — the areas where two of Dean’s nursing homes were — told NBC News they did not review the plans for his facilities.
“We do not review or approve the plans, as this is done by the Louisiana Department of Health,” said Earl Eues Jr., director of Terrebonne Parish’s Office of Homeland Security and Emergency Preparedness.
New Orleans officials reviewed the plans but declined to say if they had given any feedback, according to a city spokesman.
Only Jefferson Parish said it had raised questions about the emergency plans for two of Dean’s nursing homes, Maison deVille Nursing Home and West Jefferson Health Care. Sarah Babcock, a local emergency management official, called the facilities to “express her concerns about their reliance on evacuation for low-level hurricanes and encouraged them to consider upgrading their generators in order to shelter in place,” parish spokeswoman Rachel Strassel said.
The health department revoked the licenses and Medicaid agreements for all seven of Dean’s homes, which he is planning to appeal, McLindon said. The state attorney general has launched a criminal investigation into the warehouse deaths.
The 2021 summaries of the emergency plans for all seven facilities cited the same Independence warehouse as their evacuation site. Some of the plan summaries listed the warehouse’s capacity at 700 residents. Others said the warehouse would be “willing to host” only the total number of residents for an individual facility — 138 residents from Park Place Healthcare, for example.
Documents from Dean’s evacuation plan, released by the state, show that he charged his own nursing homes $240,000 a year to maintain access to the warehouse in Independence in case of an emergency. (McLindon, Dean’s attorney, said the money was used for maintenance and insurance, and was important to ensuring the facility was “ready to go.”)
The state health department first inspected the warehouse site in person on Aug. 27, two days before Ida made landfall in Louisiana. At the time, only 23 residents were in the facility, which was listed as having a capacity of 600, according to records released by the state. Inspectors reported no indoor toilets, 30 outdoor portable toilets, and no concerns about the site, according to inspection forms. The state health department said 200 residents were expected to arrive during the hurricane.
“They got a clean bill of health two days before the storm,” McLindon said.
Ultimately, 843 nursing home residents were brought to the facility, according to the state. Amid reports of alarming conditions, including flooding, failing generators and neglect, health inspectors returned to the property on Aug. 30. By the next day, conditions had deteriorated and four residents had died inside, while Dean allegedly expelled health inspectors from the premises, according to state records. The state began removing residents on Sept. 1, three days after the hurricane made landfall.
McLindon said the decision to move all the nursing homes to the same warehouse was in the residents’ best interest.
“He got them out of harm’s way,” he said. “You are going to hear it was overcrowded. Bob Dean made a decision to move them into the strongest building.”
Pushing for changes
Lawmakers and advocates say that more needs to be done to protect highly vulnerable residents during emergencies.
Some are pushing for more rigorous oversight on the federal level. A 2018 report from Sen. Ron Wyden, D-Ore., criticized the federal system for providing only a “very cursory level of review” for nursing homes’ emergency plans.
“If these emergency plans are to be effective, then a more thorough review-and-approval process is needed,” said the report, which was released after nursing home deaths and disastrous evacuations during Hurricanes Irma and Harvey.
The federal system relies on state officials who aren’t experts in emergency preparedness to review the plans and doesn’t require that they be shared with local authorities, according to Smetanka.
“It's really difficult for a surveyor to assess how effective the plan is or would be, when that's not what their background is,” she said. Instead, she said, the federal government could require greater involvement and review by local emergency and public health authorities to ensure the plans are “operational and realistic.”
Sen. Bob Casey, D-Pa., chair of the Senate Aging Committee, said in a statement that the federal government should do more to improve “accountability, oversight and assistance” to protect nursing home residents during natural disasters, pointing to a recent bill to fund local disaster management programs focused on older Americans.
“As climate change continues to worsen, residents of nursing homes are particularly at risk of being left behind and without adequate care,” Casey said.
In Louisiana, Bacala, the state representative, said that he is planning to work on legislation to create “more oversight process by the state” for nursing homes’ emergency plans. “We need to address what we require and how we ensure that people are safe.”
The Louisiana Department of Health said it was conducting an internal review and would have future recommendations.
“What this process should look like and where we go from here is a larger conversation we agree is needed,” the agency said in a statement.
Nursing homes should only be allowed to evacuate to other types of residential facilities, such as hotels, dormitories, or retreat centers, to protect the basic health and safety of residents, said Denise Bottcher, AARP Louisiana’s state director.
The state should also take a closer look at poorly performing nursing homes to ensure their plans are sufficient, and ensure they are reviewed locally and accessible to the public, she added.
In the event of a disaster, Bottcher said, “they should all know what's going to happen.”