    [United States Statutes at Large, Volume 134, 116th Congress, 2nd Session]
    [From the U.S. Government Publishing Office, www.gpo.gov]

    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. <>

    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.

    [[Page 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) <>  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--

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