Improving Safety and Security for Veterans Act of 2019

II 116TH CONGRESS 1ST SESSION S. 2995 To require the Secretary of Veterans Affairs to submit to Congress reports on patient safety and quality of care at medical centers of the Depart- ment of Veterans Affairs, and for other purposes. IN THE SENATE OF THE UNITED STATES DECEMBER 5, 2019 Mr. MANCHIN (for himself and Mrs. CAPITO) introduced the following bill; which was read twice and referred to the Committee on Veterans’ Affairs A BILL 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 Af- fairs, and for other purposes. Be it enacted by the Senate and House of Representa- 1 tives of the United States of America in Congress assembled, 2 SECTION 1. SHORT TITLE. 3 This Act may be cited as the ‘‘Improving Safety and 4 Security for Veterans Act of 2019’’. 5 VerDate Sep 11 2014 23:42 Dec 11, 2019 Jkt 099200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6201 E:\BILLS\S2995.IS S2995 pamtmann on DSKBC07HB2PROD with BILLS 2 •S 2995 IS SEC. 2. DEPARTMENT OF VETERANS AFFAIRS REPORTS ON 1 PATIENT SAFETY AND QUALITY OF CARE. 2 (a) REPORT ON PATIENT SAFETY AND QUALITY OF 3 CARE.— 4 (1) IN GENERAL.—Not later than 30 days after 5 the date of the enactment of this Act, the Secretary 6 of Veterans Affairs shall submit to the Committee 7 on Veterans’ Affairs of the Senate and the Com- 8 mittee on Veterans’ Affairs of the House of Rep- 9 resentatives a report regarding the policies and pro- 10 cedures of the Department relating to patient safety 11 and quality of care and the steps that the Depart- 12 ment has taken to make improvements in patient 13 safety and quality of care at medical centers of the 14 Department. 15 (2) ELEMENTS.—The report required by para- 16 graph (1) shall include the following: 17 (A) A description of the policies and proce- 18 dures of the Department and improvements 19 made by the Department with respect to the 20 following: 21 (i) How often the Department reviews 22 or inspects patient safety at medical cen- 23 ters of the Department. 24 VerDate Sep 11 2014 23:42 Dec 11, 2019 Jkt 099200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\S2995.IS S2995 pamtmann on DSKBC07HB2PROD with BILLS 3 •S 2995 IS (ii) What triggers the aggregated re- 1 view process at medical centers of the De- 2 partment. 3 (iii) What controls the Department 4 has in place for controlled and other high- 5 risk substances, including the following: 6 (I) Access to such substances by 7 staff. 8 (II) What medications are dis- 9 pensed via automation. 10 (III) What systems are in place 11 to ensure proper matching of the cor- 12 rect medication to the correct patient. 13 (IV) Controls of items such as 14 medication carts and pill bottles and 15 vials. 16 (V) Monitoring of the dispensing 17 of medication within medical centers 18 of the Department, including moni- 19 toring of unauthorized dispensing. 20 (iv) How the Department monitors 21 contact between patients and employees of 22 the Department, including how employees 23 are monitored and tracked at medical cen- 24 VerDate Sep 11 2014 23:42 Dec 11, 2019 Jkt 099200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\S2995.IS S2995 pamtmann on DSKBC07HB2PROD with BILLS 4 •S 2995 IS ters of the Department when entering and 1 exiting the room of a patient. 2 (v) How comprehensively the Depart- 3 ment uses video monitoring systems in 4 medical centers of the Department to en- 5 hance patient safety, security, and quality 6 of care. 7 (vi) How the Department tracks and 8 reports deaths at medical centers of the 9 Department at the local level, Veterans In- 10 tegrated Service Network level, and na- 11 tional level. 12 (vii) The procedures of the Depart- 13 ment to alert local, regional, and Depart- 14 ment-wide leadership when there is a sta- 15 tistically abnormal number of deaths at a 16 medical center of the Department, includ- 17 ing— 18 (I) the manner and frequency in 19 which such alerts are made; and 20 (II) what is included in such an 21 alert, such as the nature of death and 22 where within the medical center the 23 death occurred. 24 VerDate Sep 11 2014 23:42 Dec 11, 2019 Jkt 099200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\S2995.IS S2995 pamtmann on DSKBC07HB2PROD with BILLS 5 •S 2995 IS (viii) The use of root cause analyses 1 with respect to patient deaths in medical 2 centers of the Department, including— 3 (I) what threshold triggers a root 4 cause analysis for a patient death; 5 (II) who conducts the root cause 6 analysis; and 7 (III) how root cause analyses de- 8 termine whether a patient death is 9 suspicious or not. 10 (ix) What triggers a patient safety 11 alert, including how many suspicious 12 deaths cause a patient safety alert to be 13 triggered. 14 (x) The situations in which an au- 15 topsy report is ordered for deaths at hos- 16 pitals of the Department, including an 17 identification of— 18 (I) when the medical examiner is 19 called to review a patient death; and 20 (II) the official or officials that 21 decide such a review is necessary. 22 (xi) The method for family members 23 of a patient who died at a medical center 24 VerDate Sep 11 2014 23:42 Dec 11, 2019 Jkt 099200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\S2995.IS S2995 pamtmann on DSKBC07HB2PROD with BILLS 6 •S 2995 IS of the Department to request an investiga- 1 tion into that death. 2 (xii) The opportunities that exist for 3 family members of a patient who died at a 4 medical center of the Department to re- 5 quest an autopsy for that death. 6 (xiii) The methods in place for em- 7 ployees of the Department to report sus- 8 picious deaths at medical centers of the 9 Department. 10 (xiv) The steps taken by the Depart- 11 ment if an employee of the Department is 12 suspected to be implicated in a suspicious 13 death at a medical center of the Depart- 14 ment, including— 15 (I) actions to remove or suspend 16 that individual from patient care or 17 temporarily reassign that individual 18 and the speed at which that action oc- 19 curs; and 20 (II) steps taken to ensure that 21 other medical centers of the Depart- 22 ment and other non-Department med- 23 ical centers are aware of the suspected 24 VerDate Sep 11 2014 23:42 Dec 11, 2019 Jkt 099200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\S2995.IS S2995 pamtmann on DSKBC07HB2PROD with BILLS 7 •S 2995 IS role of the individual in a suspicious 1 death. 2 (xv) In the case of the suspicious 3 death of an individual while under care at 4 a medical center of the Department, the 5 methods used by the Department to inform 6 the family members of that individual. 7 (xvi) The policy of the Department for 8 communicating to the public when a sus- 9 picious death occurs at a medical center of 10 the Department. 11 (B) A description of any additional au- 12 thorities or resources needed from Congress to 13 implement any of the actions, changes to policy, 14 or other matters included in the report required 15 under paragraph (1). 16 (b) REPORT ON DEATHS AT LOUIS A. JOHNSON 17 MEDICAL CENTER.— 18 (1) IN GENERAL.—Not later than 60 days after 19 the date on which the Attorney General indicates 20 that any investigation or trial related to the sus- 21 picious deaths of veterans at the Louis A. Johnson 22 VA Medical Center in Clarksburg, West Virginia (in 23 this subsection referred to as the ‘‘Facility’’), that 24 occurred during 2017 and 2018 has sufficiently con- 25 VerDate Sep 11 2014 20:58 Dec 13, 2019 Jkt 099200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\S2995.IS S2995 pamtmann on DSKBC07HB2PROD with BILLS 8 •S 2995 IS cluded, the Secretary of Veterans Affairs shall sub- 1 mit to the Committee on Veterans’ Affairs of the 2 Senate and the Committee on Veterans’ Affairs of 3 the House of Representatives a report describing— 4 (A) the events that occurred during that 5 period related to those suspicious deaths; and 6 (B) actions taken at the Facility and 7 throughout the Department of Veterans Affairs 8 to prevent any similar reoccurrence of the 9 issues that contributed to those suspicious 10 deaths. 11 (2) ELEMENTS.—The report required by para- 12 graph (1) shall include the following: 13 (A) A timeline of events that occurred at 14 the Facility relating to the suspicious deaths 15 described in paragraph (1) beginning the mo- 16 ment those deaths were first determined to be 17 suspicious, including any notifications to— 18 (i) leadership of the Facility; 19 (ii) leadership of the Veterans Inte- 20 grated Service Network in which the Facil- 21 ity is located; 22 (iii) leadership at the central office of 23 the Department; and 24 VerDate Sep 11 2014 23:42 Dec 11, 2019 Jkt 099200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\S2995.IS S2995 pamtmann on DSKBC07HB2PROD with BILLS 9 •S 2995 IS (iv) the Office of the Inspector Gen- 1 eral of the Department of Veterans Af- 2 fairs. 3 (B) A description of the actions taken by 4 leadership of the Facility, the Veterans Inte- 5 grated Service Network in which the Facility is 6 located, and the central office of the Depart- 7 ment in response to the suspicious deaths, in- 8 cluding responses to notifications under sub- 9 paragraph (A). 10 (C) A description of the actions, including 11 root cause analyses, autopsies, or other activi- 12 ties that were conducted after each of the sus- 13 picious deaths. 14 (D) A description of the changes made by 15 the Department since the suspicious deaths to 16 procedures to control access within medical cen- 17 ters of the Department to controlled and non- 18 controlled substances to prevent harm to pa- 19 tients. 20 (E) A description of the changes made by 21 the Department to its nationwide controlled 22 substance and non-controlled substance policies 23 as a result of the suspicious deaths. 24 VerDate Sep 11 2014 23:42 Dec 11, 2019 Jkt 099200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\S2995.IS S2995 pamtmann on DSKBC07HB2PROD with BILLS 10 •S 2995 IS (F) A description of the changes planned 1 or made by the Department to its video surveil- 2 lance at medical centers of the Department to 3 improve patient safety and quality of care in re- 4 sponse to the suspicious deaths. 5 (G) An analysis of the review of sentinel 6 events conducted at the Facility in response to 7 the suspicious deaths and whether that review 8 was conducted consistent with policies and pro- 9 cedures of the Department. 10 (H) A description of the steps the Depart- 11 ment has taken or will take to improve the 12 monitoring of the credentials of employees of 13 the Department to ensure the validity of those 14 credentials, including all employees that inter- 15 act with patients in the provision of medical 16 care. 17 (I) A description of the steps the Depart- 18 ment has taken or will take to monitor and 19 mitigate the behavior of employee bad actors, 20 including those who attempt to conceal their 21 mistreatment of veteran patients. 22 (J) A description of the steps the Depart- 23 ment has taken or will take to enhance or cre- 24 ate new monitoring systems that— 25 VerDate Sep 11 2014 23:42 Dec 11, 2019 Jkt 099200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6201 E:\BILLS\S2995.IS S2995 pamtmann on DSKBC07HB2PROD with BILLS 11 •S 2995 IS (i) automatically collect and analyze 1 data from medical centers of the Depart- 2 ment and monitor for warning signs or un- 3 usual health patterns that may indicate a 4 health safety or quality problem at a par- 5 ticular medical center; and 6 (ii) automatically share those warn- 7 ings with other medical centers of the De- 8 partment, relevant Veterans Integrated 9 Service Networks, and officials of the cen- 10 tral office of the Department. 11 (K) A description of the accountability ac- 12 tions that have been taken at the Facility to re- 13 move or discipline employees who significantly 14 participated in the actions that contributed to 15 the suspicious deaths. 16 (L) A description of the system-wide re- 17 porting process that the Department will or has 18 implemented to ensure that relevant employees 19 are properly reported, when applicable, to the 20 National Practitioner Data Bank of the Depart- 21 ment of Health and Human Services, the appli- 22 cable State licensing boards, the Drug Enforce- 23 ment Administration, and other relevant enti- 24 ties. 25 VerDate Sep 11 2014 20:58 Dec 13, 2019 Jkt 099200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6201 E:\BILLS\S2995.IS S2995 pamtmann on DSKBC07HB2PROD with BILLS 12 •S 2995 IS (M) A description of any additional au- 1 thorities or resources needed from Congress to 2 implement any of the recommendations or find- 3 ings included in the report required under para- 4 graph (1). 5 (N) Such other matters as the Secretary 6 considers necessary. 7 Æ VerDate Sep 11 2014 23:42 Dec 11, 2019 Jkt 099200 PO 00000 Frm 00012 Fmt 6652 Sfmt 6301 E:\BILLS\S2995.IS S2995 pamtmann on DSKBC07HB2PROD with BILLS