[Congressional Record Volume 166, Number 194 (Monday, November 16, 2020)]
[House]
[Pages H5746-H5748]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
IMPROVING SAFETY AND SECURITY FOR VETERANS ACT OF 2019
Mrs. LURIA. Mr. Speaker, I move to suspend the rules and pass the
bill (S. 3147) 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.
The Clerk read the title of the bill.
The text of the bill is as follows:
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.
[[Page H5747]]
(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.
The SPEAKER pro tempore. Pursuant to the rule, the gentlewoman from
Virginia (Mrs. Luria) and the gentleman from Florida (Mr. Bilirakis)
each will control 20 minutes.
The Chair recognizes the gentlewoman from Virginia.
General Leave
Mrs. LURIA. Mr. Speaker, I ask unanimous consent that all Members may
have 5 legislative days in which to revise and extend their remarks and
to insert extraneous materials on S. 3147.
The SPEAKER pro tempore. Is there objection to the request of the
gentlewoman from Virginia?
There was no objection.
Mrs. LURIA. Mr. Speaker, I yield myself such time as I may consume.
Mr. Speaker, I rise in support of S. 3147, the Improving Safety and
Security for Veterans Act, introduced by Senator Manchin and Senator
Capito of West Virginia. Representative McKinley introduced a companion
measure, H.R. 5616, here in the House.
This bipartisan bill requires the Department of Veterans Affairs to
submit to Congress two critical reports relating to patient safety and
quality of care at its medical facilities.
This bill was introduced in the wake of a disturbingly tragic series
of patient deaths that occurred in 2017 and 2018 at the Clarksburg,
West Virginia, VA Medical Center.
This past July, a nursing assistant who worked at the Clarksburg VA
Medical Center pleaded guilty to seven counts of second-degree murder
and one count of assault to commit murder after unnecessarily injecting
several veteran patients with insulin with the intent to cause death.
There are no words to adequately express the sorrow we feel for the
families of veterans whose lives were tragically cut short in
Clarksburg. There are countless questions about how this could have
happened and what the Department of Veterans Affairs is doing to better
protect veteran patients in the future, not only in Clarksburg, but in
other VA facilities nationwide.
The first report outlined in this bill and mandated by S. 3147, which
is due within 30 days of enactment, requires the VA to outline the
Department's policies and procedures related to monitoring patient
safety and suspicious deaths, ensuring proper storage and access
controls for high-risk substances, trafficking employees' contact with
veteran patients, and removing from patient care employees who are
implicated in suspicious deaths.
{time} 1715
The Improving Safety and Security for Veterans Act also requires the
VA to submit to Congress an after-action report on the events that
occurred in Clarksburg. Among other things, the report will detail the
timeline of events at Clarksburg and the actions taken at the facility
level and throughout the Department of Veterans Affairs in response to
these tragic and suspicious deaths.
[[Page H5748]]
We can only hope that S. 3147, the Improving Safety and Security for
Veterans Act, will serve as a first step toward better understanding
what gaps in VA management existed and what actions the Department
still needs to take to protect our veterans.
We also hope that this measure will serve as a foundation for helping
to restore veterans' confidence in the safety, security, and quality of
the care delivered at VA medical facilities.
Mr. Speaker, I reserve the balance of my time.
Mr. BILIRAKIS. Mr. Speaker, I yield myself such time as I may
consume.
Mr. Speaker, I rise today in support of S. 3147, the Improving Safety
and Security for Veterans Act of 2019.
This bill was drafted in response to a tragic incident at the
Department of Veterans Affairs Medical Center in Clarksburg, West
Virginia, where a former VA nursing assistant killed at least seven
veteran patients by injecting them with lethal doses of insulin while
they were under her care.
As a member of the House Veterans' Affairs Committee, I personally
grieved the loss of those veterans. I cannot fathom the pain that their
loved ones must feel. My heart is with them, especially during this
holiday season.
Congress must act to ensure that no other veteran, family, or
community experiences such tragedy ever again.
Passing S. 3147 today will help us do that, Mr. Speaker. The bill
would require VA to report to Congress on the Department's efforts to
assess, monitor, and improve patient safety and quality of care
throughout the VA healthcare system. It would also require the VA to
report to Congress on the series of events surrounding the Clarksburg
murders and the actions taken in Clarksburg and nationwide, for that
matter.
We need to ensure that we learn from this tragedy and that it never,
ever is repeated.
This bill is sponsored by Senator Joe Manchin from West Virginia and
is the companion to a House bill in the House by my good friend, a
great member of the Energy and Commerce Committee, and I know he
supports veterans, David McKinley, who I will yield to in a second.
David is from West Virginia.
I appreciate Senator Manchin's and Congressman McKinley's efforts to
ensure that veterans in West Virginia and across the country receive
care that is timely, safe, and of the very highest quality. Again, we
have to thank them for their service to our country, and they are
entitled to this quality of care, Mr. Speaker.
Every veteran deserves to feel confident that they will be well cared
for when they walk through VA's doors. While nothing can bring back the
veterans who were ruthlessly murdered in Clarksburg, I hope that the
passage of this bill today will restore some of the trust that has been
lost due to this heartbreaking chapter in VA's history and ease other
veterans' fears that they may have about their own safety seeking care
through the VA healthcare system.
Mr. Speaker, I urge every one of my colleagues to join me in
supporting this bill today. I reserve the balance of my time.
Mrs. LURIA. Mr. Speaker, I reserve the balance of my time.
Mr. BILIRAKIS. Mr. Speaker, I yield such time as he may consume to
the gentleman from West Virginia (Mr. McKinley).
Mr. McKINLEY. Mr. Speaker, I rise in support of S. 3147, the
Improving Safety and Security for Veterans Act of 2019.
The bill is indeed the companion to H.R. 5616, which I introduced in
January of this year following the death of seven veterans at our
Clarksburg VA Medical Center.
A former nursing assistant at the hospital has now pled guilty to
murdering these veterans by intentionally and inappropriately injecting
them with insulin. Her actions are beyond the pale. Congress must do
everything it can to ensure that this never happens again.
This bill was just the first step toward that goal. It will, indeed,
as you heard the chairman say, provide transparency and accountability
at our VA medical facilities by requiring the VA to submit to Congress
detailed reports on patient safety and quality of care at those
hospitals.
It will also ensure that the public is well-informed as to what
occurred in Clarksburg. The public was kept in the dark for far too
long during the course of this investigation.
Our veterans have sacrificed so much for our country, and they
deserve the best possible care and should feel safe when they come to
one of our facilities.
Congress now has the opportunity to restore the public's confidence
in our Veterans Affairs system and ensure that our veterans are
receiving the care they deserve.
I join with the chairman, Mr. Speaker, in saying that I urge all of
our colleagues to join unanimously in supporting this bill.
Mr. BILIRAKIS. Mr. Speaker, I yield back the balance of my time.
Mrs. LURIA. Mr. Speaker, I have no further speakers, and I am
prepared to close. I yield myself such time as I may consume.
Mr. Speaker, I ask all of my colleagues to join me in passing S.
3147.
I want to thank Mr. McKinley for introducing this bill in the House
and Senator Manchin for working very diligently in the Senate to bring
this legislation before us today because, as Mr. McKinley said, we do
need to provide assurance to our veterans about their safety in our VA
health centers, both in Clarksburg and across the country.
I also want to thank Mr. Bilirakis, my colleague on the Veterans'
Affairs Committee, for his work on this and all the bills that we have
reviewed today.
Mr. Speaker, I urge my colleagues to join me in passing S. 3147, and
I yield back the balance of my time.
The SPEAKER pro tempore. The question is on the motion offered by the
gentlewoman from Virginia (Mrs. Luria) that the House suspend the rules
and pass the bill, S. 3147.
The question was taken.
The SPEAKER pro tempore. In the opinion of the Chair, two-thirds
being in the affirmative, the ayes have it.
Mrs. LURIA. Mr. Speaker, on that I demand the yeas and nays.
The SPEAKER pro tempore. Pursuant to section 3 of House Resolution
965, the yeas and nays are ordered.
Pursuant to clause 8 of rule XX, further proceedings on this motion
will be postponed.
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