[Congressional Bills 116th Congress]
[From the U.S. Government Publishing Office]
[S. 3147 Engrossed in Senate (ES)]

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116th CONGRESS
  1st Session
                                S. 3147

_______________________________________________________________________

                                 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.

            Passed the Senate December 19, 2019.

            Attest:

                                                             Secretary.
116th CONGRESS

  1st Session

                                S. 3147

_______________________________________________________________________

                                 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.