[116th Congress Public Law 212]
[From the U.S. Government Publishing Office]



[[Page 134 STAT. 1019]]

Public Law 116-212
116th Congress

                                 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. <<NOTE: Dec. 4, 
                          2020 -  [S. 3147]>> 

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled, <<NOTE: Improving Safety 
and Security for Veterans Act of 2019.>> 
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.

[[Page 134 STAT. 1020]]

                                    (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) <<NOTE: Procedures.>>  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) <<NOTE: Analyses.>>  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--

[[Page 134 STAT. 1021]]

                                    (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) <<NOTE: Timeline.>>  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).

[[Page 134 STAT. 1022]]

                    (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) <<NOTE: Analysis.>>  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.

[[Page 134 STAT. 1023]]

                    (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.

    Approved December 4, 2020.

LEGISLATIVE HISTORY--S. 3147:
---------------------------------------------------------------------------

CONGRESSIONAL RECORD:
                                                        Vol. 165 (2019):
                                    Dec. 19, considered and passed 
                                        Senate.
                                                        Vol. 166 (2020):
                                    Nov. 16, considered and passed 
                                        House.

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