[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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