[Congressional Record Volume 165, Number 206 (Thursday, December 19, 2019)]
[Senate]
[Pages S7211-S7212]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. MANCHIN (for himself and Mrs. Capito):
  S. 3147. A bill 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; considered and passed.

                                S. 3147

       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;

[[Page S7212]]

       (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.
                                 ______