[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.