[Congressional Bills 116th Congress]
[From the U.S. Government Publishing Office]
[H.R. 5616 Introduced in House (IH)]
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116th CONGRESS
2d Session
H. R. 5616
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.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
January 15, 2020
Mr. McKinley (for himself, Mr. Panetta, Mr. Reschenthaler, Mr. Mooney
of West Virginia, and Mrs. Miller) introduced the following bill; which
was 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 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 2020''.
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.
(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 warning 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.
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