II 118th CONGRESS 1st Session S. 3130 IN THE SENATE OF THE UNITED STATES October 25, 2023 Mr. Barrasso (for himself, Mr. Thune , Ms. Lummis , Mr. Daines , and Mr. Rounds ) introduced the following bill; which was read twice and referred to the Committee on Indian Affairs A BILL To amend the Indian Health Care Improvement Act to improve the recruitment and retention of employees in the Indian Health Service, restore accountability in the Indian Health Service, improve health services, and for other purposes.

1. Short title This Act may be cited as the Restoring Accountability in the Indian Health Service Act of 2023 . 2. Table of contents The table of contents for this Act is as follows: Sec. 1. Short title. Sec. 2. Table of contents. TITLE I—Indian Health Service improvements Sec. 101. Incentives for recruitment and retention. Sec. 102. Medical credentialing system. Sec. 103. Liability protections for health professional volunteers at Indian Health Service. Sec. 104. Clarification regarding eligibility for Indian Health Service loan repayment program. Sec. 105. Improvements in hiring practices. Sec. 106. Improved authorities of secretary to improve accountability of senior executives and employees of the Indian Health Service. Sec. 107. Tribal culture and history. Sec. 108. Staffing demonstration program. Sec. 109. Rule establishing Tribal consultation policy. Sec. 110. Enhancing quality of care in the Indian Health Service. Sec. 111. Notification of investigation regarding professional conduct; submission of records. Sec. 112. Medical chaperones; Office of Patient Advocacy. Sec. 113. Fitness of health care providers. Sec. 114. Standards to improve timeliness of care. TITLE II—Employee protections Sec. 201. Employee protections against retaliation. Sec. 202. Right of Federal employees to petition Congress. Sec. 203. Fiscal accountability. TITLE III—Reports Sec. 301. Definitions. Sec. 302. Reports by the Secretary of Health and Human Services. Sec. 303. Reports by the Comptroller General. Sec. 304. Inspector General reports. Sec. 305. Transparency in CMS surveys. TITLE IV—Technical amendments Sec. 401. Technical amendments. I Indian Health Service improvements 101. Incentives for recruitment and retention Title I of the Indian Health Care Improvement Act ( 25 U.S.C. 1611 et seq. ) is amended by adding at the end the following: 125. Incentives for recruitment and retention (a) Parity in IHS health care workforce personnel and pay system The Secretary shall establish a personnel and pay system for physicians, dentists, nurses, and other health care professionals employed by the Service that provides a personnel and pay system that, to the maximum extent practicable, is comparable to the pay provided to physicians, dentists, nurses, and other health care professionals, respectively, under subchapters III and IV of chapter 74 of title 38, United States Code. (b) Housing vouchers (1) In general Subject to paragraph (2), not later than 1 year after the date of enactment of the Restoring Accountability in the Indian Health Service Act of 2023 , the Secretary may establish a program to provide tenant-based rental assistance to an employee of the Service who— (A) agrees to serve for not less than 1 year at a Service unit designated by the Administrator of the Health Resources and Services Administration as a health professional shortage area (as defined in section 332(a) of the Public Health Service Act ( 42 U.S.C. 254e(a) )) with the greatest staffing need; and (B) is a critical employee, as determined by the Secretary. (2) Sunset Any program established by the Secretary under paragraph (1) shall terminate on the date that is 3 years after the date on which the program is established. (3) Reports Not later than 1 year after the date on which a program established under paragraph (1) is terminated in accordance with paragraph (2), the Secretary shall submit to Congress a report describing, with respect to that program— (A) the costs of the program; (B) employee uptake of the program; and (C) the effects of the program on local facility staffing needs. (c) Administration The Secretary may only provide a benefit under subsection (b) to— (1) a full-time employee who agrees to serve for not less than 1 year in the Service beginning on the date of the agreement; or (2) a part-time employee who agrees to serve for not less than 2 years in the service beginning on the date of the agreement. . 102. Medical credentialing system Title I of the Indian Health Care Improvement Act ( 25 U.S.C. 1611 et seq. ) (as amended by section 101) is amended by adding at the end the following: 126. Medical credentialing system (a) In general (1) Development and implementation timeline Not later than 1 year after the date of enactment of the Restoring Accountability in the Indian Health Service Act of 2023 , the Secretary, acting through the Service (referred to in this section as the Secretary ), in accordance with subsection (b), shall develop and implement a Service-wide centralized credentialing system (referred to in this section as the credentialing system ) to credential licensed health professionals who seek to provide health care services at any Service unit. (2) Implementation In implementing the credentialing system, the Secretary— (A) shall not require re-credentialing of licensed health professionals who were credentialed using existing Service policy prior to the date of enactment of the Restoring Accountability in the Indian Health Service Act of 2023 ; and (B) shall— (i) use the credentialing system for— (I) all applications for credentialing or re-credentialing of licensed health professionals submitted on or after the date of enactment of the Restoring Accountability in the Indian Health Service Act of 2023 ; and (II) the migration into the credentialing system of credentials data that existed prior to implementation of the credentialing system; and (ii) maintain the established timeline for re-credentialing of licensed health professionals who were credentialed prior to implementation of the credentialing system, as defined by Service policy. (b) Requirements (1) In general In developing the credentialing system under subsection (a), the Secretary shall ensure that— (A) credentialing procedures shall be uniform throughout the Service; and (B) with respect to each licensed health professional who successfully completes the credentialing procedures of the credentialing system, the Secretary may authorize the licensed health professional to provide health care services at any Service unit. (2) Exemption The requirements described in paragraph (1) shall not apply to licensed health professionals who were credentialed using existing Service policy prior to the date of enactment of the Restoring Accountability in the Indian Health Service Act of 2023 until the date on which those licensed health professionals are required to be re-credentialed in accordance with the credentialing system developed and implemented under subsection (a). (c) Consultation In developing the credentialing system under subsection (a), the Secretary— (1) shall consult with Indian tribes; and (2) may consult with— (A) any public or private association of medical providers; (B) any government agency; or (C) any other relevant expert, as determined by the Secretary. (d) Application (1) In general Subject to paragraph (2), a licensed health care professional may not provide health care services at any Service unit, unless the licensed health care professional successfully completes the credentialing procedures of the credentialing system developed and implemented under subsection (a). (2) Exemption Paragraph (1) shall not apply to licensed health professionals who were credentialed using existing Service policy prior to the date of enactment of the Restoring Accountability in the Indian Health Service Act of 2023 until the date on which those licensed health professionals are required to be re-credentialed in accordance with the credentialing system developed and implemented under subsection (a). (e) Nonduplication of efforts (1) In general To the extent that prior to the deadline described in subsection (a)(1), the Service has begun implementing or has completed implementation of a medical credentialing system that otherwise meets the requirements of this section, the Service shall not be required to establish a new credentialing system under this section. (2) Authority The Service may expand or enhance an existing credentialing system to meet the requirements of this section. (3) Review (A) In general Not less frequently than once every 5 years, the Service shall— (i) undertake a formal review of the credentialing system in effect on the date of the review; and (ii) if necessary, take action to bring the credentialing system into compliance with the requirements of this section. (B) Consultation Each formal review conducted under subparagraph (A) shall be subject to the consultation requirements under subsection (c). (f) Effect Nothing in this section— (1) negatively impacts the right of an Indian tribe to enter into a compact or contract under the Indian Self-Determination and Education Assistance Act ( 25 U.S.C. 5301 et seq. ); or (2) applies to such a compact or contract unless expressly agreed to by the Indian tribe. . 103. Liability protections for health professional volunteers at Indian Health Service Section 224 of the Public Health Service Act ( 42 U.S.C. 233 ) is amended by adding at the end the following: (r) Certain Indian Health Service volunteers deemed Public Health Service employees (1) In general For purposes of this section, a health professional volunteer at a Service unit shall, in providing a health service to an individual, be deemed to be an employee of the Public Health Service for a calendar year that begins during a fiscal year for which a transfer was made under paragraph (4)(C). The preceding sentence is subject to the provisions of this subsection. (2) Conditions In providing a health service to an individual, a health care practitioner shall, for purposes of this subsection, be considered to be a health professional volunteer at a Service unit if all of the following conditions are met: (A) The service is provided to the individual at the facilities of a Service unit, or, as authorized by the Service unit, offsite. (B) The Service unit is sponsoring the health care practitioner pursuant to paragraph (3)(C). (C) The health care practitioner does not receive any compensation for the service from the individual, the Service unit, or any third-party payer (including reimbursement under any insurance policy or health plan, or under any Federal or State health benefits program), except that the health care practitioner may receive repayment from the Service unit for reasonable expenses incurred by the health care practitioner in the provision of the service to the individual. (D) Before the service is provided, the health care practitioner or the Service unit posts a clear and conspicuous notice at the site where the service is provided of the extent to which the legal liability of the health care practitioner is limited under this subsection. (E) At the time the service is provided, the health care practitioner is licensed, certified, and credentialed in accordance with Service policy and applicable law regarding the provision of the service. (3) Applicability Subsection (g) (other than paragraphs (3) and (5)) and subsections (h), (i), and (l) apply to a health care practitioner at a Service unit for purposes of this subsection to the same extent and in the same manner as such subsections apply to an officer, governing board member, employee, or contractor of an entity described in subsection (g)(4), subject to paragraph (4) and subject to the following subparagraphs: (A) Each reference to an entity in subsections (g), (h), (i), and (l) shall be considered to be a reference to a Service unit. (B) The first sentence of paragraph (1) applies in lieu of the first sentence of subsection (g)(1)(A). (C) With respect to a Service unit, a health care practitioner is not a health professional volunteer at the Service unit unless the Service unit sponsors the health care practitioner. For purposes of this subsection, the Service unit shall be considered to be sponsoring the health care practitioner if— (i) with respect to the health care practitioner, the Service unit submits to the Secretary an application meeting the requirements of subsection (g)(1)(D); and (ii) the Secretary, pursuant to subsection (g)(1)(E), determines that the health care practitioner is deemed to be an employee of the Public Health Service. (D) In the case of a health care practitioner who is determined by the Secretary pursuant to this subsection and subsection (g)(1)(E) to be a health professional volunteer, this subsection applies to the health care practitioner (with respect to services performed on behalf of the Service unit sponsoring the health care practitioner pursuant to subparagraph (C)) for any cause of action arising from an act or omission of the health care practitioner occurring on or after the date on which the Secretary makes that determination. (E) Subsection (g)(1)(F) applies to a health care practitioner for purposes of this subsection only to the extent that, in providing health services to an individual, each of the conditions described in paragraph (2) is met. (4) Funding (A) In general Amounts appropriated under section 1304 of title 31, United States Code, commonly known as the Judgment Fund , shall be available for transfer under subparagraph (C) for purposes of carrying out this subsection, as if claims were adjudicated by a United States District Court under section 1346(b) of title 28, United States Code. (B) Annual estimates (i) In general Not later than May 1 of each fiscal year, the Attorney General, in consultation with the Secretary, shall submit to Congress a report providing an estimate of the amount of claims (together with related fees and expenses of witnesses) that, by reason of the acts or omissions of health professional volunteers, will be paid pursuant to this section during the calendar year that begins in the following fiscal year. (ii) Applicability Subsection (k)(1)(B) applies to the estimate under clause (i) relating to health professional volunteers to the same extent and in the same manner as that subsection applies to the estimate under that subsection relating to officers, governing board members, employees, and contractors of entities described in subsection (g)(4). (C) Transfers Not later than December 31 of each fiscal year, the Secretary shall transfer from the fund under subsection (k)(2) to the appropriate accounts in the Treasury an amount equal to the estimate made under subparagraph (B) for the calendar year beginning in that fiscal year, subject to the extent of amounts in the fund. (5) Definition of service unit (A) In general In this subsection, the term Service unit has the meaning given the term in section 4 of the Indian Health Care Improvement Act ( 25 U.S.C. 1603 ). (B) Inclusion In this subsection, the term Service unit includes an urban Indian organization with which the Indian Health Service has entered into a contract with, or to which the Indian Health Service has made a grant, under title V of the Indian Health Care Improvement Act ( 25 U.S.C. 1651 et seq. ). (6) Effect Nothing in this subsection— (A) negatively impacts the right of an Indian tribe or Tribal organization to enter into a compact or contract under the Indian Self-Determination and Education Assistance Act ( 25 U.S.C. 5304 et seq. ); or (B) applies to such a compact or contract unless expressly agreed to by the Indian tribe and the Secretary. (7) Effective dates (A) In general Except as provided in subparagraph (B), this subsection shall take effect on October 1, 2024. (B) Regulations, applications, and reports Effective on the date of the enactment of the Restoring Accountability in the Indian Health Service Act of 2023 , the Secretary may— (i) prescribe regulations for carrying out this subsection; and (ii) accept and consider applications submitted under paragraph (3)(C)(i). . 104. Clarification regarding eligibility for Indian Health Service loan repayment program Section 108 of the Indian Health Care Improvement Act ( 25 U.S.C. 1616a ) is amended— (1) in subsection (b)(1), by striking subparagraph (B) and inserting the following: (B) have— (i) (I) a degree in a health profession; and (II) a license to practice a health profession in a State; or (ii) (I) a master's degree in business administration with an emphasis in health care management (as defined by the Secretary), health administration, hospital administration, or public health; and (II) a license or certification to practice in the field of business administration, health administration, hospital administration, or public health in a State, if the Secretary determines the license or certification is necessary for the Indian health program to which the individual will be assigned; ; (2) in subsection (f)(1)(B), by striking clause (iii) and inserting the following: (iii) to serve for a time period (referred to in this section as the period of obligated service ) equal to— (I) 2 years or such longer period as the individual may agree to serve in the full-time practice of the individual’s profession in an Indian health program to which the individual may be assigned by the Secretary; or (II) 4 years or such longer period as the individual may agree to serve in the half-time practice of the individual’s profession in an Indian health program to which the individual may be assigned by the Secretary; ; and (3) in subsection (g)(2)— (A) in subparagraph (B), by striking (B) Any arrangement and inserting the following: (C) Deadline for repayments Any arrangement ; (B) subparagraph (A), in the second sentence of the matter preceding clause (i), by striking In making a determination and inserting the following: (B) Determination of amount of payment In making a determination under this paragraph ; and (C) by striking (2)(A) For each year and all that follows through paragraph (1). and inserting the following: (2) Authorized Payments (A) Amount of payment (i) Full-time practice In the case of an individual who contracts to serve a period of obligated service under subsection (f)(1)(B)(iii)(I), for each year of the obligated service, the Secretary may pay up to $35,000 (or an amount equal to the amount specified in section 338B(g)(2)(A) of the Public Health Service Act ( 42 U.S.C. 254l–1(g)(2)(A) )) on behalf of the individual for loans described in paragraph (1). (ii) Half-time In the case of an individual who contracts to serve a period of obligated service under subsection (f)(1)(B)(iii)(II), for each year of such obligated service, the Secretary may pay up to $17,500 (or an amount equal to half of the amount specified in section 338B(g)(2)(A) of the Public Health Service Act ( 42 U.S.C. 254l–1(g)(2)(A) )) on behalf of the individual for loans described in paragraph (1). . 105. Improvements in hiring practices (a) In general Title VI of the Indian Health Care Improvement Act ( 25 U.S.C. 1661 et seq. ) is amended by adding at the end the following: 605. Improvements in hiring practices (a) Direct hire authority The Secretary may appoint, without regard to subchapter I of chapter 33 of title 5, United States Code (other than sections 3303 and 3328 of that title), a candidate directly to a position within the Service for which the candidate meets the qualifications standard established by the Office of Personnel Management. (b) Tribal notification (1) In general Before appointing, hiring, promoting, transferring, or reassigning a candidate to a Senior Executive Service position or the position of a senior level manager at an Area office or Service unit, the Secretary shall provide notice to each Indian tribe located within the defined geographic area of the Area office or Service unit, as applicable, of the content of an inclusion in an employment record. (2) Comment period Each Indian tribe that receives notification under paragraph (1) may submit to the Secretary comments during the 10-day period after the date of notification. . (b) IHS waivers Section 2(c) of Public Law 96–135 ( 25 U.S.C. 5117(c) ) is amended— (1) in paragraph (2)— (A) by striking (2) The provisions and inserting the following: (2) Application to certain individuals The provisions ; (B) by inserting or (3) after paragraph (1) ; and (C) by striking section 1131(f) of the Education Amendments of 1978 ( 25 U.S.C. 2011(f) ; 92 Stat. 2324) and inserting section 1132(f) of the Education Amendments of 1978 ( 25 U.S.C. 2012(f) ) ; (2) by striking (c)(1) Notwithstanding and inserting the following: (c) Waiver of applicability in personnel actions (1) In general Notwithstanding ; and (3) by adding at the end the following: (3) IHS waivers (A) In general At the request of a concerned Indian tribe, the Secretary of Health and Human Services may seek from each Indian tribe concerned a waiver of Indian preference laws for a personnel action that is with respect to— (i) a Service unit (as defined in section 4 of the Indian Health Care Improvement Act ( 25 U.S.C. 1603 )) in which— (I) 15 percent or greater of the total positions are not filled by a full-time employee of the Indian Health Service for a period of 6 months or longer; or (II) 15 percent or greater of a specific health professional position are not filled by a full-time employee of the Indian Health Service for a period of 6 months or longer; or (ii) a former employee of the Indian Health Service, or a former Tribal employee, who was removed from the employment during, or demoted for performance or misconduct that occurred during, the 5-year period following the date of the personnel action. (B) Limitation A waiver may only be requested under subparagraph (A) for a personnel action that is with respect to an employee described in clause (ii) of that subparagraph if the reason for the removal or demotion of the employee did not result from an action undertaken by the employee that was reported to the National Practitioner Data Bank. (C) Restriction The Secretary of Health and Human Services may only approve a waiver under subparagraph (A) if the waiver is first requested by a concerned Indian tribe. . 106. Improved authorities of secretary to improve accountability of senior executives and employees of the Indian Health Service (a) In general Title VI of the Indian Health Care Improvement Act ( 25 U.S.C. 1661 et seq. ) (as amended by section 105(a)) is amended by adding at the end the following: 606. Improved authorities of Secretary to improve accountability of senior executives of the Indian Health Service (a) Definitions In this section: (1) Covered individual The term covered individual means a career appointee (as defined in section 3132(a) of title 5, United States Code). (2) Misconduct The term misconduct includes— (A) neglect of duty; (B) malfeasance; (C) failure to accept a directed reassignment; and (D) failure to accompany a position in a transfer of function. (3) Secretary The term Secretary means the Secretary, acting through the Service. (4) Senior executive position The term senior executive position means a Senior Executive Service position (as defined in section 3132(a) of title 5, United States Code). (b) Authority (1) In general The Secretary may, in accordance with this section, reprimand, suspend, involuntarily reassign, demote, or remove a covered individual from a senior executive position at the Service if the Secretary determines that the misconduct or performance of the covered individual warrants such an action. (2) Removal from civil service If the Secretary removes a covered individual pursuant to paragraph (1), the Secretary may remove the individual from the civil service (as defined in section 2101 of title 5, United States Code). (c) Rights and procedures (1) In general A covered individual who is the subject of an action or removal, as applicable, under subsection (b) is entitled— (A) to advance notice of the action or removal; (B) to access a file containing all evidence in support of the proposed action or removal; (C) to be represented by an attorney or other representative of the covered individual’s choice; and (D) to grieve the decision on the action or removal under paragraph (2) in accordance with the internal grievance process established by the Secretary under paragraph (3). (2) Notice; response; decision (A) In general The aggregate period for notice, response, and decision on an action or removal under subsection (b) may not exceed 15 business days. (B) Response A covered individual receiving a notice under paragraph (1)(A) of an action or removal, as applicable, under subsection (b) shall have not more than 7 business days to respond to the notice. (C) Decision (i) In general The Secretary shall issue a decision on an action or removal, as applicable, under subsection (b) not later than 15 business days after the date on which notice of the action or removal, as applicable, is received by the applicable covered individual under paragraph (1)(A). (ii) Requirements A decision under clause (i)— (I) shall be in writing; and (II) shall include the specific reasons for the decision. (D) Final and conclusive decision A decision under this paragraph that is not grieved under paragraph (3) by the deadline described in that paragraph shall be final and conclusive. (3) Grievance process (A) In general The Secretary shall establish an internal grievance process under which a covered individual may grieve a decision issued under paragraph (2) not later than the date that is 7 business days after the date on which the decision under that paragraph was issued. (B) Total period The Secretary shall issue a decision for which an internal grievance process is initiated under subparagraph (A) not later than 21 business days after the date on which the grievance process is initiated by the covered individual. (C) Final and conclusive decision A grievance decision under this paragraph shall be final and conclusive. (4) Judicial review A covered individual adversely affected by a decision under paragraph (2) that is not grieved, or by a grievance decision under paragraph (3), may obtain judicial review of the decision. (5) Court review In any case in which judicial review is sought under paragraph (4), the court shall review the record and may set aside any action of the Department or the Service found to be— (A) arbitrary, capricious, an abuse of discretion, or otherwise not in accordance with a provision of law; (B) obtained without procedures required by a provision of law having been followed; or (C) unsupported by substantial evidence. (d) Relation to other provisions of law Section 3592(b)(1) of title 5, United States Code, shall not apply to an action under subsection (b). 607. Improved authorities of Secretary to improve accountability of employees of the Indian Health Service (a) Definitions In this section: (1) Covered individual (A) In general The term covered individual means an individual occupying a position at the Service. (B) Exclusions The term covered individual does not include— (i) an individual occupying a senior executive position (as defined in section 606(a)); (ii) an individual who has not completed a probationary or trial period; or (iii) a political appointee. (2) Grade The term grade has the meaning given the term in section 7511(a) of title 5, United States Code. (3) Misconduct The term misconduct includes— (A) neglect of duty; (B) malfeasance; (C) failure to accept a directed reassignment; and (D) failure to accompany a position in a transfer of function. (4) Political appointee The term political appointee means an individual who is— (A) employed in a position described in any of sections 5312 through 5316 of title 5, United States Code (relating to the Executive Schedule); (B) a limited term appointee, limited emergency appointee, or noncareer appointee (as those terms are defined in section 3132(a) of title 5, United States Code); or (C) employed in a position of a confidential or policy-determining character under schedule C of subpart C of part 213 of title 5, Code of Federal Regulations (or a successor regulation). (5) Secretary The term Secretary means the Secretary, acting through the Service. (6) Suspend The term suspend means the placing of an employee, for disciplinary reasons, in a temporary status without duties and pay for a period in excess of 14 days. (b) Authority (1) In general The Secretary may, in accordance with this section, remove, demote, or suspend a covered individual from employment at the Service if the Secretary determines that the performance or misconduct of the covered individual warrants such an action. (2) Actions If the Secretary removes, demotes, or suspends a covered individual pursuant to paragraph (1), the Secretary may— (A) remove the covered individual from the civil service (as defined in section 2101 of title 5, United States Code); (B) demote the covered individual by means of— (i) a reduction in grade for which the covered individual is qualified, as the Secretary determines appropriate; and (ii) a reduction of the annual rate of pay of the covered individual; or (C) suspend the covered individual from the civil service (as defined in section 2101 of title 5, United States Code). (c) Pay of certain demoted individuals (1) In general Notwithstanding any other provision of law, any covered individual subject to a demotion by means of a reduction in grade under subsection (b)(2)(B) shall, beginning on the date of the demotion, receive the annual rate of pay applicable to the reduced grade. (2) Restrictions (A) Prohibition on administrative leave A covered individual subject to a demotion under subsection (b)(2)(B)— (i) may not be placed on administrative leave during the period during which an appeal (if any) under this section is ongoing; and (ii) may only receive pay if the covered individual reports for duty or is approved to use accrued unused annual, sick, family medical, military, or court leave. (B) Restriction on pay and benefits If a covered individual subject to a demotion under subsection (b)(2)(B) does not report for duty (and has not received approval to use accrued unused leave under subparagraph (A)(ii)), the covered individual shall not receive pay or other benefits pursuant to subsection (e)(7). (d) Rights and procedures (1) In general A covered individual who is the subject of an action or removal, as applicable, under subsection (b) is entitled— (A) to advance notice of the action or removal; (B) to access a file containing all evidence in support of the proposed action or removal; (C) to be represented by an attorney or other representative of the covered individual’s choice; and (D) to grieve the decision on the action or removal under paragraph (2) in accordance with the internal grievance process established by the Secretary under paragraph (3). (2) Notice; response; decision (A) Aggregate period The aggregate period for notice, response, and a final decision on an action under subsection (b) may not exceed 15 business days. (B) Response A covered individual receiving a notice under paragraph (1)(A) of an action or removal under subsection (b) shall have not more than 7 business days to respond to the notice. (C) Final and conclusive decision (i) In general The Secretary shall issue a final and conclusive decision on an action or removal under subsection (b) not later than 15 business days after the date on which the notice of the action is received by the applicable covered individual under paragraph (1)(A). (ii) Requirements A decision under clause (i)— (I) shall be in writing; and (II) shall include the specific reasons for the decision. (3) Grievance process (A) In general The Secretary shall establish an internal grievance process under which a covered individual may grieve a decision issued under paragraph (2) not later than the date that is 7 business days after the date on which the decision under that paragraph was issued. (B) Total period The Secretary shall issue a decision for which an internal grievance process is initiated under subparagraph (A) not later than 21 business days after the date on which the grievance process is initiated by the covered individual. (C) Final and conclusive decision A grievance decision under this paragraph shall be final and conclusive. (4) Procedures superseding CBAs The procedures under this subsection shall supersede any collective bargaining agreement to the extent that such an agreement is inconsistent with the procedures. (5) Performance appraisal The procedures under chapter 43 of title 5, United States Code, shall not apply to an action under subsection (b). (6) Appeal to merit systems protection board (A) In general Subject to subparagraph (B) and subsection (e), any removal, demotion, or suspension of more than 14 days under subsection (b) may be appealed to the Merit Systems Protection Board, which shall refer such appeal to an administrative law judge pursuant to section 7701(b)(1) of title 5, United States Code. (B) Time period An appeal under subparagraph (A) of a removal, demotion, or suspension may only be made if the appeal is made not later than 10 business days after the date of the removal, demotion, or suspension. (e) Expedited review (1) In general On receipt of an appeal under subsection (d)(6)(A), the applicable administrative law judge shall— (A) expedite the appeal under section 7701(b)(1) of title 5, United States Code; and (B) issue a final and complete decision on the appeal not later than 180 days after the date of the appeal. (2) Upholding decision (A) In general Notwithstanding section 7701(c)(1)(B) of title 5, United States Code, the administrative law judge shall uphold the decision of the Secretary to remove, demote, or suspend an employee under subsection (b) if the decision is supported by substantial evidence. (B) Prohibition of mitigation Notwithstanding title 5, United States Code, or any other provision of law, if the decision of the Secretary to remove, demote, or suspend an employee under subsection (b) is supported by substantial evidence, the administrative law judge shall not mitigate the penalty prescribed by the Secretary. (3) Appeal to merit systems protection board (A) In general The decision of the administrative law judge under paragraph (1) may be appealed to the Merit Systems Protection Board. (B) Upholding decision Notwithstanding section 7701(c)(1)(B) of title 5, United States Code, the Merit Systems Protection Board shall uphold the decision of the Secretary to remove, demote, or suspend an employee under subsection (b) if the decision is supported by substantial evidence. (C) Prohibition of mitigation Notwithstanding title 5, United States Code, or any other provision of law, if the decision of the Secretary is supported by substantial evidence, the Merit Systems Protection Board shall not mitigate the penalty prescribed by the Secretary. (4) Report In any case in which an administrative law judge cannot issue a final and complete decision by the deadline described in paragraph (1)(B), the Merit Systems Protection Board shall, not later than 14 business days after the deadline expires, submit to the appropriate committees of Congress a report that explains the reasons why a decision was not issued by the deadline. (5) Appeal A decision of the Merit Systems Protection Board under paragraph (3) may be appealed to the United States Court of Appeals for the Federal Circuit pursuant to section 7703 of title 5, United States Code, or to any court of appeals of competent jurisdiction pursuant to subsection (b)(1)(B) of that section. (6) Prohibition against stays The Merit Systems Protection Board may not stay any removal or demotion under subsection (b), except as provided in section 1214(b) of title 5, United States Code. (7) Restriction on pay and benefits during appeal (A) In general (i) Restriction on pay and benefits During the period described in clause (ii), a covered individual may not receive any pay and benefits described in subparagraph (B). (ii) Period described The period referred to in clause (i) is the period— (I) beginning on the date on which a covered individual appeals under this section a removal from the civil service under subsection (b)(2)(A); and (II) ending on the later of— (aa) the date on which the Merit Systems Protection Board issues a final decision on the appeal under paragraph (3); and (bb) the date on which the United States Court of Appeals for the Federal Circuit issues a final decision on the appeal under paragraph (5). (B) Pay and benefits described The pay and benefits referred to in subparagraph (A)(i) are any pay, awards, bonuses, incentives, allowances, differentials, student loan repayments, special payments, or benefits related to the employment of the individual by the Service. (8) Information to expedite appeal To the maximum extent practicable, the Secretary shall provide to the Merit Systems Protection Board such information and assistance as may be necessary to ensure an appeal under this subsection is expedited. (9) Backpay If an employee prevails on appeal under this section, the employee shall be entitled to backpay (as provided in section 5596 of title 5, United States Code). (10) Applicable timelines and procedures If an employee who is subject to a collective bargaining agreement chooses to grieve an action taken under this section through a grievance procedure provided under the collective bargaining agreement, the timelines and procedures described in subsection (d) and this subsection shall apply. (f) Alleged prohibited personnel practice In the case of a covered individual seeking corrective action (or on behalf of whom corrective action is sought) from the Office of Special Counsel based on an alleged prohibited personnel practice described in section 2302(b) of title 5, United States Code, the Secretary may not remove, demote, or suspend the covered individual under subsection (b) without the approval of the Special Counsel under section 1214(f) of title 5, United States Code. (g) Termination of investigations by Office of Special Counsel (1) In general Notwithstanding any other provision of law, the Special Counsel established by section 1211 of title 5, United States Code, may terminate an investigation of a prohibited personnel practice alleged by an employee or former employee of the Service after the Special Counsel provides to the employee or former employee a written statement of the reasons for the termination of the investigation. (2) Admissibility The statement described in paragraph (1) may not be admissible as evidence in any judicial or administrative proceeding without the consent of the employee or former employee described in paragraph (1). (h) Vacancies In the case of a covered individual who is removed or demoted under subsection (b), to the maximum extent practicable, the Secretary shall fill the vacancy arising as a result of the removal or demotion. . (b) Conforming amendments Section 4303(f) of title 5, United States Code, is amended— (1) in paragraph (3), by striking or at the end; (2) in paragraph (4), by striking the period at the end and inserting , or ; and (3) by adding at the end the following: (5) any removal or demotion under section 607 of the Indian Health Care Improvement Act. . (c) Report Not later than 18 months after the date of enactment of this Act, the Secretary of Health and Human Services or the Inspector General of the Department of Health and Human Services, as appropriate, shall submit to Congress a report that includes information on— (1) the number of employees of the Indian Health Service who were removed, demoted, or suspended during the 1-year period preceding the date of enactment of this Act; (2) the number of employees of the Indian Health Service who were removed, demoted, or suspended during the 1-year period beginning on the date of enactment of this Act pursuant to the amendments made by this section; and (3) the appropriate details of any such removals, demotions, and suspensions that lend necessary context. 107. Tribal culture and history Section 113 of the Indian Health Care Improvement Act ( 25 U.S.C. 1616f ) is amended— (1) in subsection (a)— (A) by striking a program and inserting an annual mandatory training program ; and (B) by striking appropriate employees of the Service and inserting employees of the Service, locum tenens medical providers, healthcare volunteers, and other contracted employees who work at Service hospitals or other Service units and whose employment requires regular direct patient access ; and (2) by adding at the end the following: (c) Requirement To complete training program Notwithstanding any other provision of law, beginning on the date of enactment of the Restoring Accountability in the Indian Health Service Act of 2023 , each employee or provider described in subsection (a) who enters into a contract with the Service shall, as a condition of employment, annually participate in and complete the program established under subsection (a). . 108. Staffing demonstration program Title VIII of the Indian Health Care Improvement Act ( 25 U.S.C. 1671 et seq. ) is amended by adding at the end the following: 833. Staffing demonstration program (a) In general Not later than 1 year after the date of enactment of the Restoring Accountability in the Indian Health Service Act of 2023 , the Secretary, acting through the Service (referred to in this section as the Secretary ), shall establish a demonstration program (referred to in this section as the demonstration program ) under which the Service may provide Service units with additional staffing resources, with the goal that the resources become self-sustaining. (b) Selection In selecting Service units for participation in the demonstration program, the Secretary shall consider whether a Service unit services an Indian tribe that— (1) has utilized or contributed substantial Tribal funds to construct a health facility used by the Service or identified in the master plan for the Service unit; (2) is located in 1 or more States with Medicaid reimbursements plans or policies that will increase the likelihood that the staffing resources provided will be self-sustaining; and (3) is operating a health facility described in paragraph (1) under historical staffing ratios, as determined by the Secretary, that have not been equalized or updated by the Service or any other Service program to reflect current staffing needs. (c) Duration Staffing resources provided to a Service unit under the demonstration program shall be provided for a duration that the Secretary, in consultation with the applicable Indian tribe, determines appropriate, on the condition that each staffing position provided shall be for a period of not less than 3 fiscal years. (d) Effect of staffing awards No staffing resources provided under the demonstration program shall reduce the recurring base funding for staffing for any Indian tribe or Service unit. (e) Sunset The demonstration program established under subsection (a) shall terminate on the date that is 4 years after the date on which the demonstration program is established. (f) Report Not later than 1 year after the date on which the demonstration program terminates under subsection (e), the Secretary shall submit to the Committee on Indian Affairs and the Committee on Health, Education, Labor, and Pensions of the Senate and the Committee on Natural Resources and the Committee on Energy and Commerce of the House of Representatives a report describing the demonstration program, including information on— (1) whether the staffing resources provided under the demonstration program resulted in additional revenue for the applicable Service unit sufficient to maintain the staff on a permanent basis; (2) the levels to which the staffing resources provided under the demonstration program reduced the unmet staffing need for the applicable Service unit; and (3) whether the demonstration program could be deployed permanently to reduce unmet staffing needs throughout the Service. . 109. Rule establishing Tribal consultation policy Title VIII of the Indian Health Care Improvement Act ( 25 U.S.C. 1671 et seq. ) (as amended by section 108) is amended by adding at the end the following: 834. Rule establishing Tribal consultation policy (a) In General Not later than December 31, 2023, the Secretary shall establish, and once every 5 years thereafter, the Secretary shall update, after meaningful consultation with representatives of affected Indian tribes, a rule establishing a Tribal consultation policy for the Service. (b) Contents of tribal consultation policy The policy established under the rule under subsection (a) shall— (1) update, and replace, the Tribal consultation policy established under Circular No. 2006–01 of the Service (or any successor policy); and (2) include— (A) a process for determining when and how the Service will notify Indian tribes of the availability of meaningful consultation; (B) a determination of which actions or agency decisions by the Service will trigger a requirement for meaningful consultation with Indian tribes; and (C) a determination of which actions constitute meaningful consultation with Indian tribes. . 110. Enhancing quality of care in the Indian Health Service (a) IHCIA definitions In this section, the terms Area office , Indian tribe , Secretary , Service , Service unit , tribal organization , and Urban Indian organization have the meanings given those terms in section 4 of the Indian Health Care Improvement Act ( 25 U.S.C. 1603 ). (b) Best practices for governing board and area office meetings (1) Definition of governing board In this subsection, the term governing board means the governing board of the facility of a Service unit. (2) In general Not later than 1 year after the date of enactment of this Act, the Secretary, in consultation with Indian tribes, governing boards, Area offices, Service units, and other stakeholders, as determined appropriate by the Secretary, shall establish— (A) in accordance with paragraph (3)(A), best practices for governing boards; and (B) in accordance with paragraph (3)(B), best practices for Area offices. (3) Requirements (A) Governing board best practices The best practices for governing boards established under paragraph (2)(A) shall include provisions relating to— (i) adequately monitoring the delivery of care at the applicable facility managed by the governing board; (ii) ensuring ongoing facility compliance with Federal health care program requirements, including requirements of the Service and the Centers for Medicare & Medicaid Services; (iii) handling, documenting, and responding to patient complaints; (iv) documenting, addressing, and, if applicable, reporting instances of professional misconduct by facility staff in accordance with applicable Federal and State law; (v) improving facility performance and operations with respect to mandatory and voluntary quality initiatives carried out by the Service and the Centers for Medicare & Medicaid Services; and (vi) reporting requirements under Federal law, including with respect to— (I) the Government Performance and Results Act of 1993 ( Public Law 103–62 ; 107 Stat. 285), the GPRA Modernization Act of 2010 ( Public Law 111–352 ; 124 Stat. 3866), and the amendments made by those Acts; and (II) the applicable provisions of titles XVIII and XIX of the Social Security Act ( 42 U.S.C. 1395 et seq. , 1396 et seq.). (B) Area office best practices The best practices for Area offices established under paragraph (2)(B) shall include provisions relating to— (i) strategies for how to best monitor governing board activities relating to the oversight of— (I) delivery and quality of patient care; (II) documenting and responding to patient complaints and instances of professional misconduct; and (III) facility compliance with Federal health care program requirements, including requirements of the Service and the Centers for Medicare & Medicaid Services; and (ii) connecting governing boards, including the applicable facilities of those governing boards, to resources necessary for enhancing patient outcomes and improving facility performance, including through the use of technical assistance. (4) Publication The best practices established under paragraph (2) shall be— (A) reported to, in writing, as applicable, all governing boards and Area offices; and (B) incorporated into the Indian Health Manual of the Service. (c) Review of quality and performance measures (1) Review (A) In general Not later than 1 year after the date of enactment of this Act, the Secretary, in coordination with the Agency for Healthcare Research and Quality, the National Quality Forum, Indian tribes, practitioners and administrators of the Service, and other qualified experts, as determined appropriate by the Secretary, shall undertake a review of the reported quality and performance measures of Service facilities conducted by the Secretary in accordance with— (i) section 306 of title 5, United States Code; (ii) section 1115(b) of title 31, United States Code; and (iii) any law (including regulations) used in any mandatory or voluntary program of the Centers for Medicare & Medicaid Services. (B) Report Not later than 6 months after the date on which the review required under subparagraph (A) is completed, the Secretary shall submit to Congress a report on the details and findings of that review, which shall include an assessment of— (i) the suitability of measures used as of the date of enactment of this Act for the applicable Service facility, taking into consideration the patient volume of the facility, the mix of patient cases at the facility, the geographic location of the facility, and medical professional shortage designations at the facility, as determined by the Secretary; and (ii) the extent to which the performance and quality measures are outcome-based or process-based measures. (2) Adoption Not later than 1 year after the date on which the report required under paragraph (1)(B) is submitted to Congress, the Service, in coordination with the Centers for Medicare & Medicaid Services, shall adopt, and assist Service facilities to adopt, to the extent practicable, more suitable, as compared to those quality and performance measures adopted prior to the submission of that report, quality and performance measures, including measures that are more outcome-based and process-based, in accordance with the factors described in paragraph (1)(B)(i). (3) GAO report Not later than 1 year after the date on which the report required under paragraph (1)(B) is submitted to Congress, the Comptroller General of the United States shall submit to Congress a report on challenges relating to quality measure and data collection in Service facilities, which shall include— (A) barriers to the adoption of relevant performance and quality measures in Service facilities; and (B) recommendations for how the Service, other Federal agencies, and stakeholders can assist Service facilities in adopting suitable quality and performance measures. (d) Compliance assistance program (1) Definitions In this subsection: (A) Administrator The term Administrator means the Administrator of the Centers for Medicare & Medicaid Services. (B) Eligible facility (i) In general The term eligible facility means a facility operated by the Service that— (I) is an underperforming hospital or outpatient facility; and (II) is eligible for payments under title XVIII of the Social Security Act ( 42 U.S.C. 1395 et seq. ). (ii) Inclusion The term eligible facility includes a tribally operated facility, if that facility consents to participating in the program. (C) Program The term program means the compliance assistance program established under paragraph (2). (D) Tribally operated facility The term tribally operated facility means a facility operated by an Indian tribe, a tribal organization, or an Urban Indian organization that— (i) is an underperforming hospital or outpatient facility; and (ii) is eligible for payments under title XVIII of the Social Security Act ( 42 U.S.C. 1395 et seq. ). (2) Establishment of program Not later than 1 year after the date of enactment of this Act, the Secretary, in coordination with the Administrator and quality improvement organizations having a contract with the Secretary under part B of title XI of the Social Security Act ( 42 U.S.C. 1320c et seq. ), shall establish a compliance assistance program for eligible facilities. (3) Methodology The Secretary shall establish a methodology for determining which eligible facilities shall participate in the program, which shall take into account the following factors: (A) The number and severity of facility deficiencies with respect to applicable requirements under title XVIII of the Social Security Act ( 42 U.S.C. 1395 et seq. ). (B) The history of provider misconduct or patient harm at the facility. (C) Whether there is high staff turnover at the facility. (D) Whether the facility has low performance on program quality measures, relative to other facilities of the Service, in accordance with reported quality and performance measures conducted by the Secretary in accordance with— (i) section 306 of title 5, United States Code; (ii) section 1115(b) of title 31, United States Code; and (iii) any law (including regulations) used in any mandatory or voluntary program of the Centers for Medicare & Medicaid Services. (4) Selection of facilities (A) In general The Secretary, in coordination with the Administrator, shall select not less than 25 percent of the eligible facilities to participate in the program using the methodology established under paragraph (3). (B) Participation (i) In general An eligible facility selected to participate in the program under subparagraph (A) shall be required to participate in the program. (ii) Requirement The Secretary shall ensure that, at all times during the period beginning on the date of establishment of the program and the date on which the program terminates under paragraph (8), not less than 25 percent of eligible facilities are participating in the program. (C) Term of participation (i) In general Subject to clause (ii), an eligible facility selected to participate in the program under subparagraph (A) shall participate in the program for a period of 2 years. (ii) Waiver If the Secretary, in coordination with the Administrator, certifies that an eligible facility participating in the program has improved on its performance to a satisfactory level, as determined by the Secretary, then the eligible facility does not have to participate in the program for the full 2-year period. (D) Participation limit An eligible facility may participate in the program for more than 1 2-year period. (5) Program components The program shall provide on-site consultation and educational programming for eligible facilities to ensure those eligible facilities are— (A) meeting Federal requirements of the Service and any conditions of participation applicable under title XVIII of the Social Security Act ( 42 U.S.C. 1395 et seq. ); and (B) satisfactorily implementing any quality initiatives and programs established by the Service or the Centers for Medicare & Medicaid Services. (6) Enforcement or noncompliance actions (A) In general The program shall be conducted independently of any enforcement actions under the Indian Health Care Improvement Act ( 25 U.S.C. 1601 et seq. ) or noncompliance actions taken by the Administrator with respect to noncompliance with conditions of participation applicable under title XVIII of the Social Security Act ( 42 U.S.C. 1395 et seq. ), unless, while carrying out the program, the Secretary or the Administrator, as applicable, encounters a triggering event, as determined by the Secretary or the Administrator, as applicable, that would necessitate an enforcement action or noncompliance action. (B) Triggering event encountered If a triggering event is encountered by the Secretary or Administrator under subparagraph (A), the eligible facility shall continue to participate in the program so long as the facility— (i) remains eligible for payments under title XVIII of the Social Security Act ( 42 U.S.C. 1395 et seq. ); and (ii) continues to meet all of the conditions and requirements for such payments which are applicable under such title. (7) Implementation The Secretary shall carry out the program in coordination with quality improvement organizations having a contract with the Secretary under part B of title XI of the Social Security Act ( 42 U.S.C. 1320c et seq. ). (8) Sunset The program shall terminate 6 years after the date on which the program is established. (9) Report Not later than 1 year after the date on which the program terminates under paragraph (8), the Comptroller General of the United States shall submit to Congress a report evaluating the effectiveness of the program, which shall include, to the extent practicable— (A) detailed data on changes in the patient experience at eligible facilities that participated in the program; (B) a description of the compliance status of eligible facilities that participated in the program with requirements of the Service and any conditions of participation applicable under title XVIII of the Social Security Act ( 42 U.S.C. 1395 et seq. ); and (C) a description of the progress by eligible facilities that participated in the program in meeting the goals of quality improvement activities of the Department of Health and Human Services. 111. Notification of investigation regarding professional conduct; submission of records Title VIII of the Indian Health Care Improvement Act ( 25 U.S.C. 1671 et seq. ) (as amended by section 109) is amended by adding at the end the following: 835. Notification of investigation regarding professional conduct; submission of records (a) Report Not later than 14 calendar days after the date on which the Service undertakes an investigation into the professional conduct of a licensee of a State, the Secretary, acting through the Service, shall notify the relevant State medical board of the investigation. (b) Submission of records Not later than 14 calendar days after the date on which the Service generates records relating to an investigation conducted by the Service into the professional conduct of a licensee of a State, the Secretary, acting through the Service, shall provide the records to the relevant State medical board. . 112. Medical chaperones; Office of Patient Advocacy (a) Medical chaperones Title II of the Indian Health Care Improvement Act is amended by inserting after section 223 ( 25 U.S.C. 1621v ) the following: 224. Medical chaperones (a) Indian Health Service (1) In general The Secretary, acting through the Service, shall, at the request of a patient of the Service, provide to the patient a medical chaperone, to be present during any medical examination of the patient provided by or through the Service. (2) Requirements The Secretary, acting through the Service, shall— (A) notify patients of the Service of the right to have a medical chaperone present during a medical examination provided by or through the Service; and (B) ensure that the right described in subparagraph (A) is provided to each patient in each Service unit. (b) Other providers of services An Indian tribe, tribal organization, or any other Indian health program may use amounts made available under this Act to provide, at the request of a patient to whom the Indian tribe, tribal organization, or Indian health program is providing health care services, a medical chaperone to the patient, to be present during any medical examination of the patient provided by the Indian tribe or tribal organization. . (b) Indian Health Service Office of Patient Advocacy Title VI of the Indian Health Care Improvement Act ( 25 U.S.C. 1661 et seq. ) (as amended by section 106(a)) is amended by adding at the end the following: 608. Office of Patient Advocacy (a) Definitions In this section: (1) Director The term Director means the Director of the Office. (2) Office The term Office means the Office of Patient Advocacy established by subsection (b). (b) Establishment There is established within the Department an office, to be known as the Office of Patient Advocacy . (c) Director The Office shall be headed by a Director, who shall— (1) be appointed by the Secretary from among individuals qualified to perform the duties of the position; and (2) report directly to the Secretary. (d) Duties (1) In general The Office shall carry out a patient advocacy program of the Service, under which the Office shall— (A) employ patient advocates to advocate on behalf of Indians with respect to health care services sought or received through the Service; (B) provide to those patient advocates training to ensure the advocates carry out the responsibilities described in paragraph (2); and (C) in as many prominent locations as the Director determines to be appropriate to be seen by the largest percentage of patients and family members of patients at each Service unit, display— (i) the purposes of the patient advocacy program; (ii) the contact information for a patient advocate employed at the Service unit; and (iii) a description of the rights and responsibilities of patients and family members of patients at the Service unit. (2) Patient advocate responsibilities The responsibilities of a patient advocate employed by the Office shall include the following: (A) Resolving any complaints by Indian patients with respect to health care services provided by or through the Service that cannot be resolved at— (i) the point of service; or (ii) a higher level easily accessible to the patient. (B) Expressing to Indians their rights and responsibilities as patients in receiving health care services through the Service. (C) Presenting at various meetings, and to various committees, a description of any issues experienced by Indians in receiving health care services through the Service. (D) Managing a patient advocate tracking system, if applicable. (E) Compiling data relating to any complaints made to the advocate by Indians with respect to the receipt of health care services through the Service, and the satisfaction of Indians with those services, to determine whether there exist any trends in those data. (F) Ensuring that a process exists for the distribution of data compiled under subparagraph (E) to Indian health programs, appropriate leaders, committees, and service providers, and staff of the Service. (G) Identifying, not less frequently than quarterly, opportunities for improvement in the provision of health care services to Indians by or through the Service, including based on complaints by Indian patients or immediate family members. (H) Ensuring that any significant complaint by an Indian patient or family member with respect to health care provided by or through the Service is brought to the attention of appropriate staff of the Service or Indian health program for the purpose of assessing whether further analysis of the problem is required at the Service, Service area, Service unit, or Indian health program level. (I) Supporting any other patient advocacy programs carried out by the Department. (J) Ensuring that all appeals and final decisions with respect to the receipt of health care services through the Service are entered into a patient advocate tracking system of the Office, if applicable. (K) Understanding all laws, directives, and other rules relating to the rights and responsibilities of Indians in receiving health care services through the Service, including the appeals processes available to Indian patients and immediate family members. (L) Ensuring that Indians receiving behavioral health services under title VII (and any surrogate decisionmakers for such Indians) are aware of the right of Indians— (i) to seek representation from systems established under section 103 of the Protection and Advocacy for Mentally Ill Individuals Act of 1986 ( 42 U.S.C. 10803 ); (ii) to protect and advocate for the rights of Indians experiencing behavioral health issues; and (iii) to investigate incidents of abuse and neglect of Indians experiencing behavioral health issues. (M) Achieving compliance with any applicable requirements established by the Secretary with respect to the inspection of controlled substances (as defined in section 102 of the Controlled Substances Act ( 21 U.S.C. 802 )). (N) Documenting potentially threatening behavior and reporting that behavior to the appropriate authorities. (3) Training The Director shall ensure that the training provided to patient advocates under paragraph (1)(B) is consistent throughout the Office, including with respect to any mandatory training or certification standards approved by the Director. . 113. Fitness of health care providers (a) In general Title VIII of the Indian Health Care Improvement Act is amended by inserting after section 802 ( 25 U.S.C. 1672 ) the following: 803. Fitness of health care providers (a) Additional requirements for hiring of health care providers by Service As part of the hiring process for each health care provider position at the Service after the date of enactment of the Restoring Accountability in the Indian Health Service Act of 2023 , the Director shall require from the medical board of each State in which the health care provider has or had a medical license— (1) information on any violation of the requirements of the medical license of the health care provider during the 20-year period ending on the date on which the health care provider is being considered for a position at the Service; and (2) information on whether the health care provider has entered into any settlement agreement for a disciplinary charge relating to the practice of medicine by the health care provider. (b) Provision of information on Service health care providers to State medical boards Notwithstanding section 552a of title 5, United States Code, with respect to each health care provider of the Service who has violated a requirement of the medical license of the health care provider, the Director shall provide to the medical board of each State in which the health care provider is licensed detailed information with respect to the violation, regardless of whether the medical board has formally requested that information. . (b) Report on compliance by Indian Health Service with reviews of health care providers leaving Service or transferring to other facilities Not later than 180 days after the date of enactment of this Act, the Director of the Indian Health Service shall submit to the Committee on Indian Affairs of the Senate and the Committee on Natural Resources of the House of Representatives a report on the compliance by the Indian Health Service with the policy of the Indian Health Service— (1) to conduct a review of each health care provider of the Indian Health Service who transfers to another medical facility of the Indian Health Service, resigns, retires, or is terminated to determine whether there are any concerns, complaints, or allegations of violations relating to the medical practice of the health care provider; and (2) to take appropriate action with respect to any concern, complaint, or allegation described in paragraph (1). 114. Standards to improve timeliness of care Title IV of the Indian Health Care Improvement Act ( 25 U.S.C. 1641 et seq. ) is amended by adding at the end the following: 412. Standards to improve timeliness of care (a) Regulations (1) In general Not later than 180 days after the date of enactment of the Restoring Accountability in the Indian Health Service Act of 2023 , the Secretary, acting through the Service, shall— (A) establish, by regulation, standards to measure the timeliness of the provision of health care services in Service facilities; and (B) provide such standards to each Service unit. (2) Data collection The Secretary, acting through the Service, shall develop a process for each Service unit to submit to the Secretary data with respect to the standards established under paragraph (1)(A). (b) Annual reports (1) In general Not later than 1 year after the date of enactment of the Restoring Accountability in the Indian Health Service Act of 2023 , and annually thereafter, each Area office shall submit to the Secretary a report on the metrics reported by Service units relating to the timeliness of the provision of health care services in Service facilities within each Service unit. (2) Publication The Secretary shall make each report received under paragraph (1) publicly available on the website of the Service. . II Employee protections 201. Employee protections against retaliation Title VI of the Indian Health Care Improvement Act ( 25 U.S.C. 1661 et seq. ) (as amended by section 112(b)) is amended by adding at the end the following: 609. Employee protections against retaliation (a) Definitions In this section: (1) Information The term information means information— (A) the disclosure of which is not specifically prohibited by law; and (B) that is not specifically required by Executive order to be kept secret in the interest of national defense or the conduct of foreign affairs. (2) Retaliation The term retaliation , with respect to a whistleblower, means— (A) an adverse employment action against the whistleblower; (B) a significantly adverse action against the whistleblower, such as the refusal or delay of care provided through the Service; and (C) an adverse action described in subparagraph (A) or (B) against a family member or friend of the whistleblower. (3) Whistleblower The term whistleblower means an employee of the Service who discloses information that the employee reasonably believes evidences— (A) a violation of any law, rule, regulation, or Service policy; or (B) gross mismanagement, a gross waste of funds, an abuse of authority, or a substantial and specific danger to public health or safety. (b) Employee accountability (1) Designated official The Secretary shall designate an official in the Department who is not an employee of the Service to receive reports under paragraph (2). (2) Mandatory reporting An employee of the Service who witnesses retaliation against a whistleblower, a violation of a patient safety requirement, or other similar conduct shall submit to the official designated under paragraph (1) a report of the conduct. (3) Oversight Not later than 3 days after the date on which the official designated under paragraph (1) receives a report under paragraph (2), the Secretary shall— (A) formally review the report; and (B) provide a copy of the report and any other relevant information to the Inspector General of the Department. (4) Removal for whistleblower retaliation (A) In general The Secretary may remove for misconduct from the civil service (as defined in section 2101 of title 5, United States Code), in accordance with section 606 or 607, as applicable, an employee of the Service if the Secretary determines, after completing a review described in paragraph (3), that the employee has retaliated against a whistleblower and warrants removal for misconduct. (B) Retaliation as misconduct Retaliation by an employee against a whistleblower, as described in subparagraph (A), shall be considered to be misconduct for purposes of sections 606 and 607. (5) Enhancing protections for whistleblowers The Secretary shall carry out any actions determined necessary by the Secretary to enhance protection for whistleblowers, including identifying appropriate Service employees and requiring the employees to complete the Office of Special Counsel's Whistleblower Certification Program. . 202. Right of Federal employees to petition Congress (a) Adverse action for violation of right To petition Congress Section 7211 of title 5, United States Code, is amended— (1) by striking The right of and inserting the following: (a) In general The right of ; and (2) by adding at the end the following: (b) Adverse action An employee who interferes with or denies a right protected under subsection (a) shall be subject to any adverse action described in paragraphs (1) through (5) of section 7512, in accordance with the procedure described in section 7513 and any other applicable procedure. . (b) Electronic notification of right of employees of Indian Health Service (1) In general The Secretary of Health and Human Services, acting through the Director of the Indian Health Service (referred to in this subsection as the Secretary ), shall provide, in accordance with paragraphs (2) through (5), to each employee of the Indian Health Service notice of the right to petition Congress under section 7211 of title 5, United States Code. (2) Memorandum Not later than 30 days after the date of enactment of this Act, the Secretary shall submit to the Inspector General of the Department of Health and Human Services (referred to in this subsection as the Inspector General ) a memorandum that includes the following statement: It is a violation of section 7211 of title 5, United States Code, for any Federal agency or employee to require a Federal employee to seek approval, guidance, or any other form of input prior to contacting Congress with information, even if that information is in relation to the job responsibilities of the employee. A Federal employee found to have interfered with or denied the right of another Federal employee under such section shall be subject to an adverse action described in any of paragraphs (1) through (5) of section 7512 of title 5, United States Code, including a suspension for more than 14 days without pay. . (3) Approval or disapproval (A) In general Not later than 30 days after the date on which the memorandum is submitted under paragraph (2), the Inspector General shall approve or disapprove the memorandum. (B) Disapproval If the Inspector General disapproves the memorandum, the Inspector General shall advise the Secretary on what changes to the memorandum are necessary for approval. (4) Notice If the memorandum is approved under paragraph (3), not later than 30 days after the date of the approval, the Secretary shall— (A) provide to each employee of the Indian Health Service an electronic copy of the approved memorandum; and (B) post the memorandum in a clear and conspicuous place on the website of the Indian Health Service. (5) Revised memorandum (A) In general If the memorandum is disapproved under paragraph (3), not later than 15 days after the date of disapproval, the Secretary shall submit to the Inspector General a revised memorandum that incorporates the changes advised under subparagraph (B) of that paragraph. (B) Approval or disapproval Not later than 30 days after the date on which the revised memorandum is submitted under subparagraph (A), the Inspector General shall approve the revised memorandum. (C) Notice Not later than 30 days after the date on which a revised memorandum is approved under this paragraph, the Secretary shall provide notice of the memorandum in accordance with paragraph (4). 203. Fiscal accountability Title VI of the Indian Health Care Improvement Act ( 25 U.S.C. 1661 et seq. ) (as amended by section 201) is amended by adding at the end the following: 610. Fiscal accountability (a) Management of funds (1) In general If the Secretary fails to submit a professional housing plan under section 302(a) of the Restoring Accountability in the Indian Health Service Act of 2023 or a staffing plan under section 302(b) of that Act by the applicable deadline, the Secretary may not receive, obligate, transfer, or expend any amounts for a salary increase or bonus of an individual described in paragraph (2) until the professional housing plan or staffing plan, as applicable, is submitted. (2) Individual described An individual referred to in paragraph (1) is an individual employed in the Service— (A) in a position that is— (i) described in any of sections 5312 through 5316 of title 5, United States Code; (ii) placed in level IV or V of the Executive Schedule under section 5317 of title 5, United States Code; or (iii) described in section 213.3301 or 213.3302 of title 5, Code of Federal Regulations (or a successor regulation); or (B) as a limited term appointee, limited emergency appointee, or noncareer appointee (as those terms are defined in section 3132(a) of title 5, United States Code). (b) Prioritization of patient care (1) In general The Secretary shall use amounts available to the Service that are not obligated or expended, including base budget funding and third party collections, during the fiscal years for which the amounts are made available, and that remain available, and in keeping with the purpose for which the funds were appropriated, only to support patient care by using the funds for— (A) the costs of— (i) essential medical equipment; (ii) purchased or referred care; or (iii) staffing; or (B) any other costs necessary to improve or maintain quality of care and patient safety. (2) Special rule In using amounts under paragraph (1), the Secretary shall ensure that, in any case where the amounts were originally made available for a particular Service unit, the amounts are used to benefit Indians served by that Service unit. (3) HHS plan Each applicable fiscal year, the Secretary, in consultation with Indian tribes, shall establish a plan for distributing the amounts described in paragraph (1) across the categories of uses described in subparagraphs (A) through (C) of that paragraph. (4) Restrictions The Secretary may not use amounts described in paragraph (1)— (A) to remodel or interior decorate any Area office; or (B) to increase the rate of pay of any employee of an Area office. (c) Spending reports Not later than 90 days after the end of each fiscal year, the Secretary shall submit a report describing the authorizations, expenditures, outlays, transfers, reprogramming, and obligations of each level of the Service, including the headquarters, each Area office, each Service unit, and each health clinic or facility, to— (1) each Indian tribe; (2) in the Senate— (A) the Committee on Indian Affairs; (B) the Committee on Health, Education, Labor, and Pensions; (C) the Committee on Appropriations; and (D) the Committee on the Budget; and (3) in the House of Representatives— (A) the Committee on Natural Resources; (B) the Committee on Energy and Commerce; (C) the Committee on Appropriations; and (D) the Committee on the Budget. (d) Status reports (1) Purpose The purpose of the report described in paragraph (2) is to identify the certification and accreditation status of each facility operated by the Service, Indian tribes, tribal organizations, and Urban Indian organizations. (2) Yearly report Subject to paragraph (3), not later than 180 days after the end of each fiscal year, the Secretary shall provide to each entity described in paragraphs (1) through (3) of subsection (c) a report describing the safety, billing, certification, credential, and compliance statuses of each facility managed, operated, or otherwise supported by the Service. (3) Updates With respect to any change of a status described in paragraph (2), the Secretary shall immediately provide to each entity described in paragraphs (1) through (3) of subsection (c) an update describing the change. (e) Effect Nothing in this section— (1) negatively impacts the right of an Indian tribe to enter into a compact or contract under the Indian Self-Determination and Education Assistance Act ( 25 U.S.C. 5301 et seq. ); or (2) applies to such a compact or contract unless expressly agreed to by the Indian tribe. . III Reports 301. Definitions In this title: (1) Purchased/referred care The term purchased/referred care has the meaning given the term in section 4 of the Indian Health Care Improvement Act ( 25 U.S.C. 1603 ) (as amended by section 401(a)). (2) Secretary The term Secretary means the Secretary of Health and Human Services. (3) Service The term Service means the Indian Health Service. (4) Service unit The term Service unit has the meaning given the term in section 4 of the Indian Health Care Improvement Act ( 25 U.S.C. 1603 ). (5) Tribal health program The term tribal health program has the meaning given the term in section 4 of the Indian Health Care Improvement Act ( 25 U.S.C. 1603 ). 302. Reports by the Secretary of Health and Human Services (a) IHS professional housing plan (1) In general Not later than 1 year after the date of enactment of this Act, the Secretary shall develop, make publicly available, and submit to Congress and the Comptroller General of the United States a written plan to address the professional housing needs of employees of the Service and employees of tribal health programs that comports with the practices and recommendations of the Government Accountability Office relating to professional housing included in the most recent report of the Government Accountability Office regarding Indian Health Service housing needs. (2) Requirement The plan under paragraph (1) shall include, at a minimum, projections for the professional housing needs for— (A) the 1-year period following the date of the plan; (B) the 5-year period following the date of the plan; and (C) the 10-year period following the date of the plan. (b) Plan relating to IHS staffing needs (1) In general Not later than 1 year after the date on which the Government Accountability Office releases the report described in subsection (a), the Secretary shall develop, make publicly available, and submit to Congress and the Comptroller General of the United States a written plan to address the staffing needs of the Service and tribal health programs that comports with the practices and recommendations of the Government Accountability Office relating to workforce planning included in the report. (2) Requirement The plan under paragraph (1) shall include, at a minimum, projections for the staffing needs for— (A) the 1-year period following the date of the plan; (B) the 5-year period following the date of the plan; and (C) the 10-year period following the date of the plan. 303. Reports by the Comptroller General (a) IHS housing needs report Not later than 2 years after the date on which the Comptroller General of the United States receives the professional housing plan under section 302(a), the Comptroller General shall develop and submit to Congress a report that includes— (1) an assessment of the professional housing plan; (2) an evaluation of any existing, as of the date of the report, assessments and projections for the professional housing needs of employees of the Service and employees of tribal health programs, including a discussion and conclusions as to whether the existing assessments and projections accurately reflect the professional housing needs of employees of the Service and employees of tribal health programs; and (3) an assessment of the professional housing needs of— (A) employees of the Service for each Service area (as defined in section 4 of the Indian Health Care Improvement Act ( 25 U.S.C. 1603 )); and (B) employees of tribal health programs for each Indian tribe, as applicable. (b) IHS staffing needs report (1) In general Not later than 2 years after the date on which the Comptroller General receives the plan relating to IHS staffing needs under section 302(b), the Comptroller General shall prepare and submit to Congress a report on the staffing needs of the Service and tribal health programs. (2) Contents The report under paragraph (1) shall include— (A) an assessment of the staffing plan referred to in paragraph (1); (B) a description of— (i) the number and type of full-time positions needed at each facility of the Service and at each tribal health program; and (ii) the amount of funds necessary to maintain those positions; (C) an explanation of the various methodologies that the Service uses and has previously used to determine the number and type of full-time positions needed at federally managed Service units; and (D) an assessment of the use of independent contractors, including— (i) the number of independent contractors hired to fill vacant full-time positions; and (ii) the amount of funds spent on independent contractors who provide health care services. (c) Whistleblower protections report (1) In general Not later than 1 year after the date of enactment of this Act, the Comptroller General shall develop and submit to Congress a report on the efficacy of existing protections for whistleblowers in the Service, including the protections implemented pursuant to sections 201 and 202 and the amendments made by those sections. (2) Contents The report under paragraph (1) shall include— (A) a discussion and conclusions as to whether the Service has taken proper steps to prevent retaliation against whistleblowers; (B) if applicable, any recommendations for changes to the policy of the Service with respect to whistleblowers; and (C) a discussion and conclusions as to whether the official email accounts of employees of the Service are appropriately monitored. 304. Inspector General reports (a) Patient care reports (1) Initial report Not later than 3 years after the date of enactment of this Act, the Inspector General of the Department of Health and Human Services shall develop and submit to Congress and the Service a report on deferrals and denials of care of patients by a purchased/referred care program in direct service hospitals of the Service. (2) Subsequent report Not later than 3 years after the date on which the Inspector General of the Department of Health and Human Services submits the report required by paragraph (1), the Inspector General of the Department of Health and Human Services shall develop and submit to Congress and the Service a report on patient harm events and patient deaths relating to deferrals and denials of care in the Service. (3) Requirements The reports required under paragraphs (1) and (2) shall include, as applicable— (A) (i) an evaluation of the number and kind of events that contribute to patient deaths as a result of deferrals and denials of care by a purchased/referred care program; and (ii) recommendations relating to how to reduce the number of patient harm events described in clause (i); and (B) (i) an evaluation of the tracking and reporting by the Service of, and response to, patient harm events and patient deaths that result from deferrals and denials of care; and (ii) recommendations relating to how to improve that tracking, reporting, and response. (b) Reporting systems evaluation Not later than 3 years after the date of enactment of this Act, the Inspector General of the Department of Health and Human Services shall— (1) conduct an evaluation of the patient safety incident reporting system of the Service required by the Indian Health Care Improvement Act ( 25 U.S.C. 1601 et seq. ), as of the date of enactment of this Act; and (2) provide to the Service recommendations and technical assistance regarding implementation of improved incident reporting system, procedures, standards, and protocols. 305. Transparency in CMS surveys Section 1880 of the Social Security Act ( 42 U.S.C. 1395qq ) is amended by adding at the end the following: (g) (1) With respect to each hospital described in subsection (a), standard surveys (whether conducted by the Secretary or by an accreditation organization under section 1865) to determine if such hospital meets the conditions of participation under section 1861(e) shall be conducted not later than 36 months after the date of the previous such survey. (2) With respect to each skilled nursing facility described in subsection (a), standard surveys to determine if such facility meets the conditions of participation under this title shall be conducted not later than 12 months after the date of the previous such survey. (3) Each survey completed under this subsection shall be posted on the Internet website of the Centers for Medicare & Medicaid Services. Such posting shall comply with the Federal regulations concerning the privacy of individually identifiable health information promulgated under section 264(c) of the Health Insurance Portability and Accountability Act of 1996. . IV Technical amendments 401. Technical amendments (a) Definitions Section 4 of the Indian Health Care Improvement Act ( 25 U.S.C. 1603 ) is amended— (1) in paragraph (5), by striking the paragraph designation and heading and all that follows through means and inserting the following: (5) Purchased/referred care The term purchased/referred care means ; and (2) by redesignating paragraph (5) and paragraphs (6) through (15) as paragraph (15) and paragraphs (5) through (14), respectively, and moving the paragraphs so as to appear in numerical order. (b) Technical amendments The Indian Health Care Improvement Act ( 25 U.S.C. 1601 et seq. ) is amended— (1) by striking contract health service each place it appears (regardless of casing and typeface and including in the headings) and inserting purchased/referred care (with appropriate casing and typeface); and (2) by striking contract health services each place it appears (regardless of casing and typeface and including in the headings) and inserting purchased/referred care (with appropriate casing and typeface).