,,ii  #aafth ,,congress  #ast ,session  
,s4 #biie  ,,in ,,the ,,senate ,,of     
,,the ,,united ,,states  ,december #e1  
#bjai,mr4 ,manchin 7for himself and     
,mrs4 ,capito7 introduced the following 
bill2 which was read twice and referred 
to the ,committee on ,veterans' ,affairs
  ,a ,,bill  ,to require the ,secretary 
of ,veterans ,affairs to submit to      
,congress reports on patient safety and 
quality of care at medical centers of   
the ,department of ,veterans ,affairs1  
and for other purposes4  #a4 ,short     
title ,this ,act may be cited as the    
,improving ,safety and ,security for    
,veterans ,act of #bjai4  #b4           
,department of ,veterans ,affairs       
reports on patient safety and quality of
 care  7a7 ,report on patient safety and
 quality of care  7#a7 ,in general ,not 
later than #cj days after the date of   
the enactment of this ,act1 the         
,secretary of ,veterans ,affairs shall  
submit to the ,committee on ,veterans'  
,affairs of the ,senate and the         

,committee on ,veterans' ,affairs of the
 ,house of ,representatives a report    
regarding the policies and procedures of
 the ,department relating to patient    
safety and quality of care and the steps
 that the ,department has taken to make 
improvements in patient safety and      
quality of care at medical centers of   
the ,department4  7#b7 ,elements ,the   
report required by paragraph 7#a7 shall 
include the following3 7,a7 ,a          
description of the policies and         
procedures of the ,department and       
improvements made by the ,department    
with respect to the following3  7i7 ,how
 often the ,department reviews or       
inspects patient safety at medical      
centers of the ,department4  7ii7 ,what 
triggers the aggregated review process  
at medical centers of the ,department4  
7iii7 ,what controls the ,department has
 in place for controlled and other      
high-risk substances1 including the     
following3  7,i7 ,access to such        
substances by staff4  7,,ii7 ,what      

medications are dispensed via           
automation4  7,,iii7 ,what systems are  
in place to ensure proper matching of   
the correct medication to the correct   
patient4  7,,iv7 ,controls of items such
 as medication carts and pill bottles   
and vials4  7,v7 ,monitoring of the     
dispensing of medication within medical 
centers of the ,department1 including   
monitoring of unauthorized dispensing4  
7iv7 ,how the ,department monitors      
contact between patients and employees  
of the ,department1 including how       
employees are monitored and tracked at  
medical centers of the ,department when 
entering and exiting the room of a      
patient4  7v7 ,how comprehensively the  
,department uses video monitoring       
systems in medical centers of the       
,department to enhance patient safety1  
security1 and quality of care4  7vi7    
,how the ,department tracks and reports 
deaths at medical centers of the        
,department at the local level1         
,veterans ,integrated ,service ,network 

level1 and national level4  7vii7 ,the  
procedures of the ,department to alert  
local1 regional1 and ,department-wide   
leadership when there is a statistically
 abnormal number of deaths at a medical 
center of the ,department1 including--  
7,i7 the manner and frequency in which  
such alerts are made2 and  7,,ii7 what  
is included in such an alert1 such as   
the nature of death and where within the
 medical center the death occurred4     
7viii7 ,the use of root cause analyses  
with respect to patient deaths in       
medical centers of the ,department1     
including--  7,i7 what threshold        
triggers a root cause analysis for a    
patient death2  7,,ii7 who conducts the 
root cause analysis2 and  7,,iii7 how   
root cause analyses determine whether a 
patient death is suspicious or not4     
7ix7 ,what triggers a patient safety    
alert1 including how many suspicious    
deaths cause a patient safety alert to  
be triggered4  7x7 ,the situations in   
which an autopsy report is ordered for  

deaths at hospitals of the ,department1 
including an identification of--  7,i7  
when the medical examiner is called to  
review a patient death2 and  7,,ii7 the 
official or officials that decide such a
 review is necessary4  7xi7 ,the method 
for family members of a patient who died
 at a medical center of the ,department 
to request an investigation into that   
death4  7xii7 ,the opportunities that   
exist for family members of a patient   
who died at a medical center of the     
,department to request an autopsy for   
that death4  7xiii7 ,the methods in     
place for employees of the ,department  
to report suspicious deaths at medical  
centers of the ,department4  7xiv7 ,the 
steps taken by the ,department if an    
employee of the ,department is suspected
 to be implicated in a suspicious death 
at a medical center of the ,department1 
including--  7,i7 actions to remove or  
suspend that individual from patient    
care or temporarily reassign that       
individual and the speed at which that  

action occurs2 and  7,,ii7 steps taken  
to ensure that other medical centers of 
the ,department and other               
non-,department medical centers are     
aware of the suspected role of the      
individual in a suspicious death4  7xv7 
,in the case of the suspicious death of 
an individual while under care at a     
medical center of the ,department1 the  
methods used by the ,department to      
inform the family members of that       
individual4  7xvi7 ,the policy of the   
,department for communicating to the    
public when a suspicious death occurs at
 a medical center of the ,department4   
7,b7 ,a description of any additional   
authorities or resources needed from    
,congress to implement any of the       
actions1 changes to policy1 or other    
matters included in the report required 
under paragraph 7#a74  7b7 ,report on   
deaths at ,louis ,a4 ,johnson ,medical  
,center  7#a7 ,in general ,not later    
than #fj days after the date on which   
the ,attorney ,general indicates that   

any investigation or trial related to   
the suspicious deaths of veterans at the
 ,louis ,a4 ,johnson ,,va ,medical      
,center in ,clarksburg1 ,west ,virginia 
7in this subsection referred to as the  
,facility71 that occurred during #bjag  
and #bjah has sufficiently concluded1   
the ,secretary of ,veterans ,affairs    
shall submit to the ,committee on       
,veterans' ,affairs of the ,senate and  
the ,committee on ,veterans' ,affairs of
 the ,house of ,representatives a report
 describing--  7,a7 the events that     
occurred during that period related to  
those suspicious deaths2 and  7,b7      
actions taken at the ,facility and      
throughout the ,department of ,veterans 
,affairs to prevent any similar         
reoccurrence of the issues that         
contributed to those suspicious deaths4 
7#b7 ,elements ,the report required by  
paragraph 7#a7 shall include the        
following3 7,a7 ,a timeline of events   
that occurred at the ,facility relating 
to the suspicious deaths described in   

paragraph 7#a7 beginning the moment     
those deaths were first determined to be
 suspicious1 including any notifications
 to--  7i7 leadership of the ,facility2 
7ii7 leadership of the ,veterans        
,integrated ,service ,network in which  
the ,facility is located2  7iii7        
leadership at the central office of the 
,department2 and  7iv7 the ,office of   
the ,inspector ,general of the          
,department of ,veterans ,affairs4  7,b7
 ,a description of the actions taken by 
leadership of the ,facility1 the        
,veterans ,integrated ,service ,network 
in which the ,facility is located1 and  
the central office of the ,department in
 response to the suspicious deaths1     
including responses to notifications    
under subparagraph 7,a74  7,c7 ,a       
description of the actions1 including   
root cause analyses1 autopsies1 or other
 activities that were conducted after   
each of the suspicious deaths4  7,d7 ,a 
description of the changes made by the  
,department since the suspicious deaths 

to procedures to control access within  
medical centers of the ,department to   
controlled and non-controlled substances
 to prevent harm to patients4  7,e7 ,a  
description of the changes made by the  
,department to its nationwide controlled
 substance and non-controlled substance 
policies as a result of the suspicious  
deaths4  7,f7 ,a description of the     
changes planned or made by the          
,department to its video surveillance at
 medical centers of the ,department to  
improve patient safety and quality of   
care in response to the suspicious      
deaths4  7,g7 ,an analysis of the review
 of sentinel events conducted at the    
,facility in response to the suspicious 
deaths and whether that review was      
conducted consistent with policies and  
procedures of the ,department4  7,h7 ,a 
description of the steps the ,department
 has taken or will take to improve the  
monitoring of the credentials of        
employees of the ,department to ensure  
the validity of those credentials1      

including all employees that interact   
with patients in the provision of       
medical care4  7,i7 ,a description of   
the steps the ,department has taken or  
will take to monitor and mitigate the   
behavior of employee bad actors1        
including those who attempt to conceal  
their mistreatment of veteran patients4 
7,j7 ,a description of the steps the    
,department has taken or will take to   
enhance or create new monitoring systems
 that--  7i7 automatically collect and  
analyze data from medical centers of the
 ,department and monitor for warning    
signs or unusual health patterns that   
may indicate a health safety or quality 
problem at a particular medical center2 
and  7ii7 automatically share those     
warnings with other medical centers of  
the ,department1 relevant ,veterans     
,integrated ,service ,networks1 and     
officials of the central office of the  
,department4  7,k7 ,a description of the
 accountability actions that have been  
taken at the ,facility to remove or     

discipline employees who significantly  
participated in the actions that        
contributed to the suspicious deaths4   
7,l7 ,a description of the system-wide  
reporting process that the ,department  
will or has implemented to ensure that  
relevant employees are properly         
reported1 when applicable1 to the       
,national ,practitioner ,data ,bank of  
the ,department of ,health and ,human   
,services1 the applicable ,state        
licensing boards1 the ,drug ,enforcement
 ,administration1 and other relevant    
entities4  7,m7 ,a description of any   
additional authorities or resources     
needed from ,congress to implement any  
of the recommendations or findings      
included in the report required under   
paragraph 7#a74  7,n7 ,such other       
matters as the ,secretary considers     
necessary4