Section 545.APPENDIX A Sexual Assault Treatment Plan Form

Sexual Assault Treatment Plan

Instructions: This form describes the minimum components of a Sexual Assault Treatment Plan. References to the “Regulations” mean the Illinois Department of Public Health Sexual Assault Survivors Emergency Treatment Code (77 Ill. Adm. Code 545). All responses shall be written as clearly and succinctly as possible. If additional sheets are necessary, attach those sheets to the page on which the information is originally requested. A completed copy of the plan shall be retained by the hospital. The completed plan shall be sent to:

Illinois Department of Public Health

Division of Health Facilities and Programs

525 West Jefferson Street, 4^th Floor

Springfield, Illinois 62761-0001

PART A

Name of Treatment Hospital:

Mailing Address:

Contact Person for Program:

(Name)

(Job Title)

(Telephone Number)

(Fax Number)

Contact Person for Billing:

(Name)

(Job Title)

(Telephone Number)

(Fax Number)

Estimated number of patients served in coming FY:

Community or Area-wide Plan:

Yes

If yes, names of participating transfer facilities:

PART B

1. Describe the geographic area to be covered by the treatment facility, procedures that will be adopted that are compatible with the needs of alleged sexual assault survivors, type of staff available, and steps that will be taken for public education at least annually to ensure that such a program is understood by other medical facilities, police, State’s Attorneys, local sexual assault crisis centers, social services agencies, and citizens groups. If the treatment facility is part of a community or areawide plan, the hospital shall formalize the arrangements by contracts, letters of agreement or standard operating procedures. (See Section 545.60 of the Regulations and attach any agreements to the plan).

2. Describe any local ordinance, municipal codes, rules or regulationsthat apply to the health care or reporting procedures for alleged sexual assault survivors in the hospital’s area.

3. State that the Evidence Collection Kit Medical Report Form for Sexual Assault Cases is used as a permanent medical record and approved by your Records Review Committee. (See Section 545.60(b) of the Regulations).

4. Attach copies of appropriate forms distributed to alleged sexual assault survivors that describe:

a) Risk of sexually transmitted diseases and infections.

b) Types of medication for sexually transmitted diseases and side effects.

c) Medical procedures, medication given, and possible contraindications of such medication.

d) Necessity of two week follow-up visit .

e) Information concerning emergency contraception in accordance with Section 545.95 of the Regulations. The Evidence Collection Kit Patient Information Sheet shall be used as a component of written information distribution. (See Section 545.60(d of the Regulations.)

f) Date rape drug testing information, including an explanation of the comprehensive scope of drug screen and the limited time frame within which such evidence can be collected.

5. Describe evidence collection procedures to be taken. The Illinois State Police Evidence Collection Instruction Sheet and Notes to Forensic Examiner Sheet may be used and attached.

6. Describe counseling available for sexual assault survivors. Counseling services shall comply with Section 545.60(d) of the Regulations.

PART C

Review and sign the Conditions of Approval:

CONDITIONS OF APPROVAL

The following conditions of approval shall apply to all Sexual Assault Emergency Treatment Programs. These conditions are enumerated below to ensure that all treatment facilities are informed and aware of their responsibilities in accordance with the Sexual Assault Survivors Emergency Treatment Code (77 Ill. Adm. Code 545) and the Sexual Assault Survivors Emergency Treatment Act [410 ILCS 70]

1. The hospital shall provide hospital emergency services to alleged sexual assault survivors, with the consent of the sexual assault survivor and as ordered by the attending physician, in accordance with the Sexual Assault Survivors Emergency Treatment Act and with the Sexual Assault Survivors Emergency Treatment Code (seeSection 545.60 of the Regulations).

2. The hospital shall provide such services at no direct charge to the patient. If the patient is neither eligible to receive such services under the Illinois Public Aid Code nor is covered by a policy of insurance, the hospital shall seek reimbursement only from the Illinois Department of Public Aid (IDPA).

3. The hospital shall submit billings to IDPA on properly authenticated vouchers supplied by IDPA for all eligible patients for whom hospital emergency services were provided pursuant to its approved Treatment Plan.

4. The hospital shall maintain and preserve all patient medical records in a manner and for a duration established by hospital policy and for not less than 10 years, in accordance with Section 6.17 of the Hospital Licensing Act.

5. The hospital shall maintain all business and professional records in accordance with acceptable business and accounting practices, and all records shall be legible. Records shall be retained for a period of not less than three years after the date of service or as required by State law, whichever period is longer, except that if an audit is initiated within the required retention period, the records shall be retained until the audit is completed and every exception is resolved.

6. The hospital shall comply with the reporting procedures for sexual assault survivors as required by Section 3.2 of the Criminal Identification Act [20 ILCS 2630].

7. The hospital shall post information in the emergency department concerning crime victim compensation to comply with the Crime Victims Compensation Act [740 ILCS 45].

FOR THE HOSPITAL:

Administrator

(Source: Amended at 27 Ill. Reg. 1567, effective January 15, 2003)