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