,,ii  #aaf? ,,congress  #a/ ,session    
,s4 #cadg  ,,9 ,,! ,,s5ate ,,( ,,!      
,,unit$ ,,/ates  ,decemb] #ai1 #bjai,mr4
 ,man*9 7= himself & ,mrs4 ,capito7     
introduc$ ! foll[+ bill2 :i* 0 read     
twice1 consid]$1 read ! ?ird "t1 & pass$
  ,a ,,bill  ,to require ! ,secret>y (  
,vet]ans ,affairs to submit to ,congress
 reports on pati5t safety & quality (   
c>e at m$ical c5t]s ( ! ,dep>tm5t (     
,vet]ans ,affairs1 & = o!r purposes4    
#a4 ,%ort title ,?is ,act may be cit$ z 
! ,improv+ ,safety & ,security =        
,vet]ans ,act ( #bjai4  #b4 ,dep>tm5t ( 
,vet]ans ,affairs reports on pati5t     
safety & quality ( c>e  7a7 ,report on  
pati5t safety & quality ( c>e  7#a7 ,9  
g5]al ,n lat] ?an #cj days aft] ! date (
 ! enactm5t ( ?is ,act1 ! ,secret>y (   
,vet]ans ,affairs %all submit to !      
,committee on ,vet]ans' ,affairs ( !    
,s5ate & ! ,committee on ,vet]ans'      
,affairs ( ! ,h\se ( ,repres5tatives a  
report reg>d+ ! policies & proc$ures ( !
 ,dep>tm5t relat+ to pati5t safety &    

quality ( c>e & ! /eps t ! ,dep>tm5t has
 tak5 to make improvem5ts 9 pati5t      
safety & quality ( c>e at m$ical c5t]s (
 ! ,dep>tm5t4  7#b7 ,elem5ts ,! report  
requir$ by p>agraph 7#a7 %all include ! 
foll[+3 7,a7 ,a description ( ! policies
 & proc$ures ( ! ,dep>tm5t & improvem5ts
 made by ! ,dep>tm5t ) respect to !     
foll[+3  7i7 ,h[ (t5 ! ,dep>tm5t reviews
 or inspects pati5t safety at m$ical    
c5t]s ( ! ,dep>tm5t4  7ii7 ,:at trigg]s 
! aggregat$ review process at m$ical    
c5t]s ( ! ,dep>tm5t4  7iii7 ,:at        
controls ! ,dep>tm5t has 9 place =      
controll$ & o!r high-risk sub/ances1    
includ+ ! foll[+3  7,i7 ,access to su*  
sub/ances by /aff4  7,,ii7 ,:at         
m$ications are disp5s$ via automation4  
7,,iii7 ,:at sy/ems are 9 place to      
ensure prop] mat*+ ( ! correct m$ication
 to ! correct pati5t4  7,,iv7 ,controls 
( items su* z m$ication c>ts & pill     
bottles & vials4  7,v7 ,monitor+ ( !    
disp5s+ ( m$ication )9 m$ical c5t]s ( ! 
,dep>tm5t1 includ+ monitor+ ( unau?oriz$

 disp5s+4  7iv7 ,h[ ! ,dep>tm5t monitors
 contact betwe5 pati5ts & employees ( ! 
,dep>tm5t1 includ+ h[ employees are     
monitor$ & track$ at m$ical c5t]s ( !   
,dep>tm5t :5 ent]+ & exit+ ! room ( a   
pati5t4  7v7 ,h[ compreh5sively !       
,dep>tm5t uses video monitor+ sy/ems 9  
m$ical c5t]s ( ! ,dep>tm5t to enhance   
pati5t safety1 security1 & quality (    
c>e4  7vi7 ,h[ ! ,dep>tm5t tracks &     
reports dea?s at m$ical c5t]s ( !       
,dep>tm5t at ! local level1 ,vet]ans    
,integrat$ ,s]vice ,network level1 &    
national level4  7vii7 ,! proc$ures ( ! 
,dep>tm5t to al]t local1 regional1 &    
,dep>tm5t-wide lead]%ip :5 !re is a     
/ati/ically abnormal numb] ( dea?s at a 
m$ical c5t] ( ! ,dep>tm5t1 includ+--    
7,i7 ! mann] & frequ5cy 9 :i* su* al]ts 
are made2 &  7,,ii7 :at is includ$ 9 su*
 an al]t1 su* z ! nature ( dea? & :]e )9
 ! m$ical c5t] ! dea? occurr$4  7viii7  
,! use ( root cause analyses ) respect  
to pati5t dea?s 9 m$ical c5t]s ( !      
,dep>tm5t1 includ+--  7,i7 :at ?re%old  

trigg]s a root cause analysis = a pati5t
 dea?2  7,,ii7 :o conducts ! root cause 
analysis2 &  7,,iii7 h[ root cause      
analyses det]m9e :e!r a pati5t dea? is  
suspici\s or n4  7ix7 ,:at trigg]s a    
pati5t safety al]t1 includ+ h[ _m       
suspici\s dea?s cause a pati5t safety   
al]t to be trigg]$4  7x7 ,! situations 9
 :i* an autopsy report is ord]$ = dea?s 
at hospitals ( ! ,dep>tm5t1 includ+ an  
id5tification (--  7,i7 :5 ! m$ical     
exam9] is call$ to review a pati5t dea?2
 &  7,,ii7 ! (ficial or (ficials t      
decide su* a review is necess>y4  7xi7  
,! me?od = family memb]s ( a pati5t :o  
di$ at a m$ical c5t] ( ! ,dep>tm5t to   
reque/ an inve/igation into t dea?4     
7xii7 ,! opportunities t exi/ = family  
memb]s ( a pati5t :o di$ at a m$ical    
c5t] ( ! ,dep>tm5t to reque/ an autopsy 
= t dea?4  7xiii7 ,! me?ods 9 place =   
employees ( ! ,dep>tm5t to report       
suspici\s dea?s at m$ical c5t]s ( !     
,dep>tm5t4  7xiv7 ,! /eps tak5 by !     
,dep>tm5t if an employee ( ! ,dep>tm5t  

is suspect$ to be implicat$ 9 a         
suspici\s dea? at a m$ical c5t] ( !     
,dep>tm5t1 includ+--  7,i7 actions to   
remove or susp5d t individual f pati5t  
c>e or tempor>ily reassign t individual 
& ! spe$ at :i* t action occurs2 &      
7,,ii7 /eps tak5 to ensure t o!r m$ical 
c5t]s ( ! ,dep>tm5t & o!r non-,dep>tm5t 
m$ical c5t]s are aw>e ( ! suspect$ role 
( ! individual 9 a suspici\s dea?4  7xv7
 ,9 ! case ( ! suspici\s dea? ( an      
individual :ile "u c>e at a m$ical c5t] 
( ! ,dep>tm5t1 ! me?ods us$ by !        
,dep>tm5t to in=m ! family memb]s ( t   
individual4  7xvi7 ,! policy ( !        
,dep>tm5t = communicat+ to ! public :5 a
 suspici\s dea? occurs at a m$ical c5t] 
( ! ,dep>tm5t4  7,b7 ,a description (   
any additional au?orities or res\rces   
ne$$ f ,congress to implem5t any ( !    
actions1 *anges to policy1 or o!r matt]s
 includ$ 9 ! report requir$ "u p>agraph 
7#a7  7b7 ,report on dea?s at ,l\is ,a4 
,johnson ,m$ical ,c5t]  7#a7 ,9 g5]al ,n
 lat] ?an #fj days aft] ! date on :i* ! 

,attorney ,g5]al indicates t any        
inve/igation or trial relat$ to !       
suspici\s dea?s ( vet]ans at ! ,l\is ,a4
 ,johnson ,,va ,m$ical ,c5t] 9          
,cl>ksburg1 ,we/ ,virg9ia1 79 ?is       
subsection ref]r$ to z ! ,facility7 t   
occurr$ dur+ #bjag & #bjah has          
suffici5tly conclud$1 ! ,secret>y (     
,vet]ans ,affairs %all submit to !      
,committee on ,vet]ans' ,affairs ( !    
,s5ate & ! ,committee on ,vet]ans'      
,affairs ( ! ,h\se ( ,repres5tatives a  
report describ+--  7,a7 ! ev5ts t       
occurr$ dur+ t p]iod relat$ to ^?       
suspici\s dea?s2 &  7,b7 actions tak5 at
 ! ,facility & ?r\gh\t ! ,dep>tm5t (    
,vet]ans ,affairs to prev5t any simil>  
reoccurr5ce ( ! issues t contribut$ to  
^? suspici\s dea?s4  7#b7 ,elem5ts ,!   
report requir$ by p>agraph 7#a7 %all    
include ! foll[+3 7,a7 ,a timel9e (     
ev5ts t occurr$ at ! ,facility relat+ to
 ! suspici\s dea?s describ$ 9 p>agraph  
7#a7 beg9n+ ! mom5t ^? dea?s 7 fir/     
det]m9$ to be suspici\s1 includ+ any    

notifications to--  7i7 lead]%ip ( !    
,facility2  7ii7 lead]%ip ( ! ,vet]ans  
,integrat$ ,s]vice ,network 9 :i* !     
,facility is locat$2  7iii7 lead]%ip at 
! c5tral (fice ( ! ,dep>tm5t2 &  7iv7 ! 
,(fice ( ! ,inspector ,g5]al ( !        
,dep>tm5t ( ,vet]ans ,affairs4  7,b7 ,a 
description ( ! actions tak5 by lead]%ip
 ( ! ,facility1 ! ,vet]ans ,integrat$   
,s]vice ,network 9 :i* ! ,facility is   
locat$1 & ! c5tral (fice ( ! ,dep>tm5t 9
 response to ! suspici\s dea?s1 includ+ 
responses to notifications "u           
subp>agraph 7,a74  7,c7 ,a description (
 ! actions1 includ+ root cause analyses1
 autopsies1 or o!r activities t 7       
conduct$ aft] ea* ( ! suspici\s dea?s4  
7,d7 ,a description ( ! *anges made by !
 ,dep>tm5t s9ce ! suspici\s dea?s to    
proc$ures to control access )9 m$ical   
c5t]s ( ! ,dep>tm5t to controll$ &      
non-controll$ sub/ances to prev5t h>m to
 pati5ts4  7,e7 ,a description ( !      
*anges made by ! ,dep>tm5t to its       
nationwide controll$ sub/ance &         

non-controll$ sub/ance policies z a     
result ( ! suspici\s dea?s4  7,f7 ,a    
description ( ! *anges plann$ or made by
 ! ,dep>tm5t to its video surveillance  
at m$ical c5t]s ( ! ,dep>tm5t to improve
 pati5t safety & quality ( c>e 9        
response to ! suspici\s dea?s4  7,g7 ,an
 analysis ( ! review ( s5t9el ev5ts     
conduct$ at ! ,facility 9 response to ! 
suspici\s dea?s & :e!r t review 0       
conduct$ consi/5t ) policies & proc$ures
 ( ! ,dep>tm5t4  7,h7 ,a description ( !
 /eps ! ,dep>tm5t has tak5 or w take to 
improve ! monitor+ ( ! cr$5tials (      
employees ( ! ,dep>tm5t to ensure !     
validity ( ^? cr$5tials1 includ+ all    
employees t int]act ) pati5ts 9 !       
provision ( m$ical c>e4  7,i7 ,a        
description ( ! /eps ! ,dep>tm5t has    
tak5 or w take to monitor & mitigate !  
behavior ( employee bad actors1 includ+ 
^? :o attempt to conceal _! mi/reatm5t (
 vet]an pati5ts4  7,j7 ,a description ( 
! /eps ! ,dep>tm5t has tak5 or w take to
 enhance or create new monitor+ sy/ems  

t--  7i7 automatically collect & analyze
 data f m$ical c5t]s ( ! ,dep>tm5t &    
monitor = w>n+s signs or unusual heal?  
patt]ns t may indicate a heal? safety or
 quality problem at a p>ticul> m$ical   
c5t]2 &  7ii7 automatically %>e ^? w>n+s
 ) o!r m$ical c5t]s ( ! ,dep>tm5t1      
relevant ,vet]ans ,integrat$ ,s]vice    
,networks1 & (ficials ( ! c5tral (fice (
 ! ,dep>tm5t4  7,k7 ,a description ( !  
acc\ntability actions t h be5 tak5 at ! 
,facility to remove or discipl9e        
employees :o significantly p>ticipat$ 9 
! actions t contribut$ to ! suspici\s   
dea?s4  7,l7 ,a description ( !         
sy/em-wide report+ process t ! ,dep>tm5t
 w or has implem5t$ to ensure t relevant
 employees are prop]ly report$1 :5      
applicable1 to ! ,national ,practition] 
,data ,bank ( ! ,dep>tm5t ( ,heal? &    
,human ,s]vices1 ! applicable ,/ate     
lic5s+ bo>ds1 ! ,drug ,en=cem5t         
,adm9i/ration1 & o!r relevant entities4 
7,m7 ,a description ( any additional    
au?orities or res\rces ne$$ f ,congress 

to implem5t any ( ! recomm5dations or   
f9d+s includ$ 9 ! report requir$ "u     
p>agraph 7#a74  7,n7 ,su* o!r matt]s z !
 ,secret>y consid]s necess>y4