I 

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. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Improving Safety and 

5 Security for Veterans Act of 2020’’. 


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1 SEC. 2. DEPARTMENT OF VETERANS AFFAIRS REPORTS ON 

2 PATIENT SAFETY AND QUALITY OF CARE. 

3 (a) REPORT ON PATIENT SAFETY AND QUALITY OF

4 CARE.— 

5 (1) IN GENERAL.—Not later than 30 days after 

6 the date of the enactment of this Act, the Secretary 

7 of Veterans Affairs shall submit to the Committee 

8 on Veterans’ Affairs of the Senate and the Com9 mittee on Veterans’ Affairs of the House of Rep10 resentatives a report regarding the policies and pro11 cedures of the Department relating to patient safety 

12 and quality of care and the steps that the Depart13 ment has taken to make improvements in patient 

14 safety and quality of care at medical centers of the 

15 Department. 

16 (2) ELEMENTS.—The report required by para17 graph (1) shall include the following: 

18 (A) A description of the policies and proce19 dures of the Department and improvements 

20 made by the Department with respect to the 

21 following: 

22 (i) How often the Department reviews 

23 or inspects patient safety at medical cen24 ters of the Department. 


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1 (ii) What triggers the aggregated re2 view process at medical centers of the De3 partment. 

4 (iii) What controls the Department 

5 has in place for controlled and other high6 risk substances, including the following: 

7 (I) Access to such substances by 

8 staff. 

9 (II) What medications are dis10 pensed via automation. 

11 (III) What systems are in place 

12 to ensure proper matching of the cor13 rect medication to the correct patient. 

14 (IV) Controls of items such as 

15 medication carts and pill bottles and 

16 vials. 

17 (V) Monitoring of the dispensing 

18 of medication within medical centers 

19 of the Department, including moni20 toring of unauthorized dispensing. 

21 (iv) How the Department monitors 

22 contact between patients and employees of 

23 the Department, including how employees 

24 are monitored and tracked at medical cenVerDate Sep 11 2014 22:34 Jan 16, 2020 Jkt 099200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\H5616.IH H5616

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1 ters of the Department when entering and 

2 exiting the room of a patient. 

3 (v) How comprehensively the Depart4 ment uses video monitoring systems in 

5 medical centers of the Department to en6 hance patient safety, security, and quality 

7 of care. 

8 (vi) How the Department tracks and 

9 reports deaths at medical centers of the 

10 Department at the local level, Veterans In11 tegrated Service Network level, and na12 tional level. 

13 (vii) The procedures of the Depart14 ment to alert local, regional, and Depart15 ment-wide leadership when there is a sta16 tistically abnormal number of deaths at a 

17 medical center of the Department, includ18 ing— 

19 (I) the manner and frequency in 

20 which such alerts are made; and 

21 (II) what is included in such an 

22 alert, such as the nature of death and 

23 where within the medical center the 

24 death occurred. 


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1 (viii) The use of root cause analyses 

2 with respect to patient deaths in medical 

3 centers of the Department, including— 

4 (I) what threshold triggers a root 

5 cause analysis for a patient death; 

6 (II) who conducts the root cause 

7 analysis; and 

8 (III) how root cause analyses de9 termine whether a patient death is 

10 suspicious or not. 

11 (ix) What triggers a patient safety 

12 alert, including how many suspicious 

13 deaths cause a patient safety alert to be 

14 triggered. 

15 (x) The situations in which an au16 topsy report is ordered for deaths at hos17 pitals of the Department, including an 

18 identification of— 

19 (I) when the medical examiner is 

20 called to review a patient death; and 

21 (II) the official or officials that 

22 decide such a review is necessary. 

23 (xi) The method for family members 

24 of a patient who died at a medical center 


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1 of the Department to request an investiga2 tion into that death. 

3 (xii) The opportunities that exist for 

4 family members of a patient who died at a 

5 medical center of the Department to re6 quest an autopsy for that death. 

7 (xiii) The methods in place for em8 ployees of the Department to report sus9 picious deaths at medical centers of the 

10 Department. 

11 (xiv) The steps taken by the Depart12 ment if an employee of the Department is 

13 suspected to be implicated in a suspicious 

14 death at a medical center of the Depart15 ment, including— 

16 (I) actions to remove or suspend 

17 that individual from patient care or 

18 temporarily reassign that individual 

19 and the speed at which that action oc20 curs; and 

21 (II) steps taken to ensure that 

22 other medical centers of the Depart23 ment and other non-Department med24 ical centers are aware of the suspected 


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1 role of the individual in a suspicious 

2 death. 

3 (xv) In the case of the suspicious 

4 death of an individual while under care at 

5 a medical center of the Department, the 

6 methods used by the Department to inform 

7 the family members of that individual. 

8 (xvi) The policy of the Department for 

9 communicating to the public when a sus10 picious death occurs at a medical center of 

11 the Department. 

12 (B) A description of any additional au13 thorities or resources needed from Congress to 

14 implement any of the actions, changes to policy, 

15 or other matters included in the report required 

16 under paragraph (1). 

17 (b) REPORT ON DEATHS AT LOUIS A. JOHNSON

18 MEDICAL CENTER.— 

19 (1) IN GENERAL.—Not later than 60 days after 

20 the date on which the Attorney General indicates 

21 that any investigation or trial related to the sus22 picious deaths of veterans at the Louis A. Johnson 

23 VA Medical Center in Clarksburg, West Virginia (in 

24 this subsection referred to as the ‘‘Facility’’), that 

25 occurred during 2017 and 2018 has sufficiently conVerDate Sep 11 2014 22:34 Jan 16, 2020 Jkt 099200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\H5616.IH H5616

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1 cluded, the Secretary of Veterans Affairs shall sub2 mit to the Committee on Veterans’ Affairs of the 

3 Senate and the Committee on Veterans’ Affairs of 

4 the House of Representatives a report describing— 

5 (A) the events that occurred during that 

6 period related to those suspicious deaths; and 

7 (B) actions taken at the Facility and 

8 throughout the Department of Veterans Affairs 

9 to prevent any similar reoccurrence of the 

10 issues that contributed to those suspicious 

11 deaths. 

12 (2) ELEMENTS.—The report required by para13 graph (1) shall include the following: 

14 (A) A timeline of events that occurred at 

15 the Facility relating to the suspicious deaths 

16 described in paragraph (1) beginning the mo17 ment those deaths were first determined to be 

18 suspicious, including any notifications to— 

19 (i) leadership of the Facility; 

20 (ii) leadership of the Veterans Inte21 grated Service Network in which the Facil22 ity is located; 

23 (iii) leadership at the central office of 

24 the Department; and 


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1 (iv) the Office of the Inspector Gen2 eral of the Department of Veterans Af3 fairs. 

4 (B) A description of the actions taken by 

5 leadership of the Facility, the Veterans Inte6 grated Service Network in which the Facility is 

7 located, and the central office of the Depart8 ment in response to the suspicious deaths, in9 cluding responses to notifications under sub10 paragraph (A). 

11 (C) A description of the actions, including 

12 root cause analyses, autopsies, or other activi13 ties that were conducted after each of the sus14 picious deaths. 

15 (D) A description of the changes made by 

16 the Department since the suspicious deaths to 

17 procedures to control access within medical cen18 ters of the Department to controlled and non19 controlled substances to prevent harm to pa20 tients. 

21 (E) A description of the changes made by 

22 the Department to its nationwide controlled 

23 substance and non-controlled substance policies 

24 as a result of the suspicious deaths. 


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1 (F) A description of the changes planned 

2 or made by the Department to its video surveil3 lance at medical centers of the Department to 

4 improve patient safety and quality of care in re5 sponse to the suspicious deaths. 

6 (G) An analysis of the review of sentinel 

7 events conducted at the Facility in response to 

8 the suspicious deaths and whether that review 

9 was conducted consistent with policies and pro10 cedures of the Department. 

11 (H) A description of the steps the Depart12 ment has taken or will take to improve the 

13 monitoring of the credentials of employees of 

14 the Department to ensure the validity of those 

15 credentials, including all employees that inter16 act with patients in the provision of medical 

17 care. 

18 (I) A description of the steps the Depart19 ment has taken or will take to monitor and 

20 mitigate the behavior of employee bad actors, 

21 including those who attempt to conceal their 

22 mistreatment of veteran patients. 

23 (J) A description of the steps the Depart24 ment has taken or will take to enhance or cre25 ate new monitoring systems that— 


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1 (i) automatically collect and analyze 

2 data from medical centers of the Depart3 ment and monitor for warning signs or un4 usual health patterns that may indicate a 

5 health safety or quality problem at a par6 ticular medical center; and 

7 (ii) automatically share those warn8 ings with other medical centers of the De9 partment, relevant Veterans Integrated 

10 Service Networks, and officials of the cen11 tral office of the Department. 

12 (K) A description of the accountability ac13 tions that have been taken at the Facility to re14 move or discipline employees who significantly 

15 participated in the actions that contributed to 

16 the suspicious deaths. 

17 (L) A description of the system-wide re18 porting process that the Department will or has 

19 implemented to ensure that relevant employees 

20 are properly reported, when applicable, to the 

21 National Practitioner Data Bank of the Depart22 ment of Health and Human Services, the appli23 cable State licensing boards, the Drug Enforce24 ment Administration, and other relevant enti25 ties. 


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1 (M) A description of any additional au2 thorities or resources needed from Congress to 

3 implement any of the recommendations or find4 ings included in the report required under para5 graph (1). 

6 (N) Such other matters as the Secretary 

7 considers necessary. 

Æ 


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