[Congressional Bills 116th Congress]
[From the U.S. Government Publishing Office]
[S. 3147 Enrolled Bill (ENR)]

        S.3147

                     One Hundred Sixteenth Congress

                                 of the

                        United States of America


                          AT THE SECOND SESSION

           Begun and held at the City of Washington on Friday,
            the third day of January, two thousand and twenty


                                 An Act


 
   To require the Secretary of Veterans Affairs to submit to Congress 
reports on patient safety and quality of care at medical centers of the 
         Department of Veterans Affairs, and for other purposes.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
    This Act may be cited as the ``Improving Safety and Security for 
Veterans Act of 2019''.
SEC. 2. DEPARTMENT OF VETERANS AFFAIRS REPORTS ON PATIENT SAFETY AND 
QUALITY OF CARE.
    (a) Report on Patient Safety and Quality of Care.--
        (1) In general.--Not later than 30 days after the date of the 
    enactment of this Act, the Secretary of Veterans Affairs shall 
    submit to the Committee on Veterans' Affairs of the Senate and the 
    Committee on Veterans' Affairs of the House of Representatives a 
    report regarding the policies and procedures of the Department 
    relating to patient safety and quality of care and the steps that 
    the Department has taken to make improvements in patient safety and 
    quality of care at medical centers of the Department.
        (2) Elements.--The report required by paragraph (1) shall 
    include the following:
            (A) A description of the policies and procedures of the 
        Department and improvements made by the Department with respect 
        to the following:
                (i) How often the Department reviews or inspects 
            patient safety at medical centers of the Department.
                (ii) What triggers the aggregated review process at 
            medical centers of the Department.
                (iii) What controls the Department has in place for 
            controlled and other high-risk substances, including the 
            following:

                    (I) Access to such substances by staff.
                    (II) What medications are dispensed via automation.
                    (III) What systems are in place to ensure proper 
                matching of the correct medication to the correct 
                patient.
                    (IV) Controls of items such as medication carts and 
                pill bottles and vials.
                    (V) Monitoring of the dispensing of medication 
                within medical centers of the Department, including 
                monitoring of unauthorized dispensing.

                (iv) How the Department monitors contact between 
            patients and employees of the Department, including how 
            employees are monitored and tracked at medical centers of 
            the Department when entering and exiting the room of a 
            patient.
                (v) How comprehensively the Department uses video 
            monitoring systems in medical centers of the Department to 
            enhance patient safety, security, and quality of care.
                (vi) How the Department tracks and reports deaths at 
            medical centers of the Department at the local level, 
            Veterans Integrated Service Network level, and national 
            level.
                (vii) The procedures of the Department to alert local, 
            regional, and Department-wide leadership when there is a 
            statistically abnormal number of deaths at a medical center 
            of the Department, including--

                    (I) the manner and frequency in which such alerts 
                are made; and
                    (II) what is included in such an alert, such as the 
                nature of death and where within the medical center the 
                death occurred.

                (viii) The use of root cause analyses with respect to 
            patient deaths in medical centers of the Department, 
            including--

                    (I) what threshold triggers a root cause analysis 
                for a patient death;
                    (II) who conducts the root cause analysis; and
                    (III) how root cause analyses determine whether a 
                patient death is suspicious or not.

                (ix) What triggers a patient safety alert, including 
            how many suspicious deaths cause a patient safety alert to 
            be triggered.
                (x) The situations in which an autopsy report is 
            ordered for deaths at hospitals of the Department, 
            including an identification of--

                    (I) when the medical examiner is called to review a 
                patient death; and
                    (II) the official or officials that decide such a 
                review is necessary.

                (xi) The method for family members of a patient who 
            died at a medical center of the Department to request an 
            investigation into that death.
                (xii) The opportunities that exist for family members 
            of a patient who died at a medical center of the Department 
            to request an autopsy for that death.
                (xiii) The methods in place for employees of the 
            Department to report suspicious deaths at medical centers 
            of the Department.
                (xiv) The steps taken by the Department if an employee 
            of the Department is suspected to be implicated in a 
            suspicious death at a medical center of the Department, 
            including--

                    (I) actions to remove or suspend that individual 
                from patient care or temporarily reassign that 
                individual and the speed at which that action occurs; 
                and
                    (II) steps taken to ensure that other medical 
                centers of the Department and other non-Department 
                medical centers are aware of the suspected role of the 
                individual in a suspicious death.

                (xv) In the case of the suspicious death of an 
            individual while under care at a medical center of the 
            Department, the methods used by the Department to inform 
            the family members of that individual.
                (xvi) The policy of the Department for communicating to 
            the public when a suspicious death occurs at a medical 
            center of the Department.
            (B) A description of any additional authorities or 
        resources needed from Congress to implement any of the actions, 
        changes to policy, or other matters included in the report 
        required under paragraph (1)
    (b) Report on Deaths at Louis A. Johnson Medical Center.--
        (1) In general.--Not later than 60 days after the date on which 
    the Attorney General indicates that any investigation or trial 
    related to the suspicious deaths of veterans at the Louis A. 
    Johnson VA Medical Center in Clarksburg, West Virginia, (in this 
    subsection referred to as the ``Facility'') that occurred during 
    2017 and 2018 has sufficiently concluded, the Secretary of Veterans 
    Affairs shall submit to the Committee on Veterans' Affairs of the 
    Senate and the Committee on Veterans' Affairs of the House of 
    Representatives a report describing--
            (A) the events that occurred during that period related to 
        those suspicious deaths; and
            (B) actions taken at the Facility and throughout the 
        Department of Veterans Affairs to prevent any similar 
        reoccurrence of the issues that contributed to those suspicious 
        deaths.
        (2) Elements.--The report required by paragraph (1) shall 
    include the following:
            (A) A timeline of events that occurred at the Facility 
        relating to the suspicious deaths described in paragraph (1) 
        beginning the moment those deaths were first determined to be 
        suspicious, including any notifications to--
                (i) leadership of the Facility;
                (ii) leadership of the Veterans Integrated Service 
            Network in which the Facility is located;
                (iii) leadership at the central office of the 
            Department; and
                (iv) the Office of the Inspector General of the 
            Department of Veterans Affairs.
            (B) A description of the actions taken by leadership of the 
        Facility, the Veterans Integrated Service Network in which the 
        Facility is located, and the central office of the Department 
        in response to the suspicious deaths, including responses to 
        notifications under subparagraph (A).
            (C) A description of the actions, including root cause 
        analyses, autopsies, or other activities that were conducted 
        after each of the suspicious deaths.
            (D) A description of the changes made by the Department 
        since the suspicious deaths to procedures to control access 
        within medical centers of the Department to controlled and non-
        controlled substances to prevent harm to patients.
            (E) A description of the changes made by the Department to 
        its nationwide controlled substance and non-controlled 
        substance policies as a result of the suspicious deaths.
            (F) A description of the changes planned or made by the 
        Department to its video surveillance at medical centers of the 
        Department to improve patient safety and quality of care in 
        response to the suspicious deaths.
            (G) An analysis of the review of sentinel events conducted 
        at the Facility in response to the suspicious deaths and 
        whether that review was conducted consistent with policies and 
        procedures of the Department.
            (H) A description of the steps the Department has taken or 
        will take to improve the monitoring of the credentials of 
        employees of the Department to ensure the validity of those 
        credentials, including all employees that interact with 
        patients in the provision of medical care.
            (I) A description of the steps the Department has taken or 
        will take to monitor and mitigate the behavior of employee bad 
        actors, including those who attempt to conceal their 
        mistreatment of veteran patients.
            (J) A description of the steps the Department has taken or 
        will take to enhance or create new monitoring systems that--
                (i) automatically collect and analyze data from medical 
            centers of the Department and monitor for warnings signs or 
            unusual health patterns that may indicate a health safety 
            or quality problem at a particular medical center; and
                (ii) automatically share those warnings with other 
            medical centers of the Department, relevant Veterans 
            Integrated Service Networks, and officials of the central 
            office of the Department.
            (K) A description of the accountability actions that have 
        been taken at the Facility to remove or discipline employees 
        who significantly participated in the actions that contributed 
        to the suspicious deaths.
            (L) A description of the system-wide reporting process that 
        the Department will or has implemented to ensure that relevant 
        employees are properly reported, when applicable, to the 
        National Practitioner Data Bank of the Department of Health and 
        Human Services, the applicable State licensing boards, the Drug 
        Enforcement Administration, and other relevant entities.
            (M) A description of any additional authorities or 
        resources needed from Congress to implement any of the 
        recommendations or findings included in the report required 
        under paragraph (1).
            (N) Such other matters as the Secretary considers 
        necessary.

                               Speaker of the House of Representatives.

                            Vice President of the United States and    
                                               President of the Senate.