franscian-st-james-101520_redacted

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SURVEYOR [oC DATESuveYCOWRETED STATEMENT OF DEFICIENCIES er an aie AND PLAN OF CORRECTION wore ATECRETE anmam Syegaris eeercon one rcpSome Err OnET one Pveron pe RESUKTOR DEHTIING FORMATION crossREFERAZD YoThEASPROPRUATE DERRCENCY) ote RSF Ene RT CT es ssn) my———— on sess moran ranSTS rnrrhe [ltteer ericson syns mets ona, ostreat prey 300 my 101420705.030 2 sete0 Sr Eo tte eo vansatomsa— rss 0010142038 primey0 mesonsace vies EC carn evra rote ! | | i | | RATE FRR gm —— Vartsenest re 2212   SEXUAL ASSAULT EVIDENCE COLLECTION TIP SHEET Offer evidence collection and Sane services to anyone presenting with complaint of sexual assault ideally within last 7 days. Evidence collection can be done up to 30 days if suspected evidence may be found or survivor requests Do not ask for specific deta of assault ules you ae performing the evidence callcion kit and doing documentation. Multiple people should not document.If a SANE is documenting, physician notes should just read “see SANE documentation”. All patients presenting with concern for STDs should be questioned regarding circumstances of exposure. Anyone exposed unilingly should be ven the option of evidence colectonit appropriate. Ifoffered and declined, a refusal should be signed. DOCUMENT THIS ConveRsamion! REMINDER... sexual assault does not have to be violent. Coerced sex, sex while impaired copnitvely una give consent and testing are ssa Seshhe races ofa man nonconsensually and covertly removing a condom after his partner explicitly expressed that intercourse is subject only to the use of a condom. Any patient presenting under suspicious circumstances or when assault is suspected and the patient cannot ake an informed decision regain evidence collection du to mtoxation or Creumstances that wil resolv na reasonable amount of time, the tape of evidence collection should be revisited when the patient is able to understand and make an informed decision. Any potential evidence should be preserved as well as possible until that time. Cal SANE on-call Kari with any questions or when n doubt Pediatric assaults- Consult Karin or Advocate Hope Children’s ER or Lurie’s Children’s ER with ‘questions regarding need for acute transfer or scheduled follow up for evidence collection/interview. Pediatric ptints re prepubescent o under the geof 18and acing the mental capably 10 understand and give Informed consent o evidence collection. Consul Karn beyond puberty hrough age 18 and unable to gv consent REMEMBER. tsnot th patient's responsibilty toaskfoevidence colecton is our responsibilty to offer,  Policy Number: ER-119 Section: Emergency Department PURPOSE: To provide comprehensive acute care, reatment, evidence collection, appropriate referral for follow-up care, counseling, and comprehensive documentation for ll adulv/adolescen sexual assault vietims in accordance with Sexual Assault Survivors Emergency Treatment Code (77 ILL Adm. Codes 545) Prepubescent pediatric victims will be transferred in accordance to an agreed upon contractual facility with an accepting physician and/or SANE nurse. PROCEDURE: A. Notify appropriate police department andY.W.C.ARES. orthe hospital Social Service representative. B. The Emergency Department nurses will ender comprehensive competent care: 1. A member ofthe health cae team shall respond within minutes to move the survivor toa closed environment o ensure privacy. Health care personnel shall refer to survivors by code to avoid embarrassment. 2. Thehospital shall offer to calla friend or family member. The rape crisis advocate will be called 0 accompany the survivor. 3. Conducta swifl initial assessment of the needsand support required preventing further trauma. 4. Provide prompt treatment for physical injury andevidence collection withina private environment, with only examining health care personnel, any translator needed and, if indicated (with consentofsurvivor), a specially trained advocate and an support person of the survivors choosing,if requested. . Facilitate appropriate follow-up care witha physician licensed to practice medicine in all ofits branches as provided in Medical Practice Act of 1987. Payment voucher to be: provided to eligible patiens. 6. Recognize special diagnostic and therapeutic needsofthe sexually assaulted and amange for appropriate careon case by case basis — (refer to attached procedure “Toxicology Screen for date-rape victims”. 7. The hospital will provide emergency contzacepion information and treatment in accordance with IDPH Section 545.35.1 Each survivorofsexual assault will receive ‘medically and factually accurate oral and written information about emergency contraception as soon as possible and can be administer within 96 hours. When a survivor presents herselfa the hospital for emergency treatment services; the indications and contraindications and risks associated with the useof emergency contraception; and a descriptionofhow and when survivors will be provided emergency contraception upon the ‘written order ofa physician licensed to practice medicine. A female survivorofsexual assault who shows a negative result for pregnancy and whose history corresponds to this will be offered an emergency contraceptive intervention.Ifthe sexual assault survivor accepts this treatment, the emergency contraceptive willbe provided in the emergency department Ifthe survivor presents a poscve result on th tests, the survivor wil be counseled thatthe: emergency department will not offer the formulation. If the est is positive for pregnancy, the sexual assault survivor will be counseled that this pregnancy is not ofimmediateor recent origin. CLINICAL APPLICATION C. Evidence/Specimen Collection 1. Follow current protocols for evidence collection kits provided by the State of linois. An offer to complete a Sexual Assault Evidence Collection kit for any sexual assault survivor who presents within a minimumofthe last 7 daysofthe assault or who has disclosed past sexual assault by a specific individual and was in the careof that individual within a ‘minimum ofthe last 7 days. 2. Obiain consent for treatment, consent for photos, and for releaseofevidence from the patient, thus insuring all information and evidence may be released 10 the appropriate law enforcement agency. 3. Ifthe case ofa survivor who is a minor 13 yearsofage or older, evidence and information conceming the sexual assaultmaybe released at the writen consentofthe minor.If the survivor is a minor who is less than 13 years ofage, or prepubescent evidence and information concerning the sexual assault may be released at the written consentofthe parent, guardian, investigating aw enforcement office or Department ofChildren and Family Services. Ifthe survivor is an adult who has a guardian ofthe person,a health care surrogate, or an agent acting under the health care power ofattomey, then consent ofthe ‘guardian, surogate, o agent i not required to release evidence and information conceming the sexual assault. If the adult is unable to provide consent for the release of evidence and information and a guardian, surrogate, or agent under a health care power of attomey is unavailable or unwilling to release the information, then an investigating law enforcement officer may authorize th release. 4. Photographsof indications of trauma may be taken for evidentiary purposes with the written consentofthe sexual assault survivor or the survivor's parent or guardian if the survivor is less than 13 yearsof ge,o prepubescent. If the survivoris less than3 years of age, or prepubescent and the parent or guardian is not immediately available, photographs ‘may be taken and shal be released to aw enforcement personnel and State's Attomey stall ‘when written consent is blained from a parca, guardian, or law enforcement officer, oF the Departmentof Children and Family Services. 5. Complete all required forms and distribute as instructed inthe kit 6. Recheck that al specimens ae labeled and scaled with appropriate tape. All specimens must be labeled with a. Exact sourceofthe specimen b. Patient name . Nameof person collecting the specimens d. Date and time specimens collected 7. Offer patienta showeraftr evidence collection is completed. 8. As soon as practical, but in no event more than 4 hours afer the completion of medical forensic services, the hospital shall make reasonable efforts 0 determine the aw enforcement agency having jurisdiction where the assault occurred, contact said agency and noify that the hospital is in possession of sexual assault evidenceand the date and time the collection was completed. This notification date and time and nameofnotified shallbedocumented in the medical record. 9. Ifthe law enforcement agency having jurisdiction has not taken physical custody ofthe sexual assault evidence within 5 daysofthe fist contact by the hospital, the hospital shall renotify the agency and document as such in the medical record. 10, Ifthe law enforcement agency having jurisdiction has not takenphysical custody ofthe sexual assault evidence within 10 daysofth initial contact by the hospital, the hospital shall contact the State's Attorneyof the counly where the law enforcemen agency having jurisdiction is located to report the possession of evidence, date and time of collection, the law enforcement agency having jurisdiction and date, time and names of persons notified at said agency. This notification shall be made within 14 daysof the collection of the sexual assault evidence. n “The kits to be kept in a secure locked place until released to legal authority ‘maintaining chainofcustody. The officer accepting custody must siga the appropriate forms as well a the evidence kit self. D. Treatment 1. Treatment should include the following: careof physical injuries, prevention of sexually transmitted diseases and anticipationofpsychological consequences. 2. Laboratory Examinationof assaulted vitim should include, butnotbe limited to: Beta HCG (beta human chorionic gonadotropin level), VDRL, hepatitis panel acute and rapid HIV screening, or any additional test ordered by the Emergency Department physician. 3. Ifa STD is suspectedorconfirmed, the patient will receive the proper medication. In addition, the victim wil be given a prescription for follow-up treatment, when necessary. 4. HIV prophylaxis shallbe explainedandoffered 10victimspreseating within 72 hours of assault as deemed appropriate by the attending physician, advanced practice nurse or physician assistant in accordance with CDC guidelines. Ifaccepted by the victim, an initial dose shall be offered at the hospital with a prescription for the remaining regimen given. E. Discharge 1. The patient will be instructed (0 seck follow-up care with their personal physician. Ifthe patient does nothave a personal physician, she/he will be given follow-up information according to protocol. The patient wil be instructed to follow-up within 24 - 48 hours afer hei visit to the Emergency Center. 2. The sexual assault survivor will receive information and follow-up referrals as appropriate, to maximize recovery. Rape Hotline 1-800-656 HOPE (4473) South Suburban Family Shelter, Ine. (708) 335-4125 YWCA Metropolitan Comittee against Rape ‘Suburban District 24 hours day (708) 748.5672 ‘The Emergency Department registered nurse i responsible for providing appropriate literature such as: 1. "After sexual assault” 2. "Crime Victims" Social Services ora representative from Y.W.C.A.R E.S may assist withthe support process. F. Sexual assault survivors shall be informedoftheir rights under the Victims of Violent Crimes & Compensation Act. Accordingly, the hospital shall provide emergency services a nodirect charge o the survivor. Ifthe survivor is neither cligble to receive services under the llinois Public Aid Code nor covered by a policy of insurance, the hospital shall eck reimbursement only from the linois Department of Healthcare and Family Services (HFS), according to procedures established by HFS for that purpose (Hospital Services, 89 ILL. Admin. Code 148). The hospital shall submit billings to HFS or properly. authenticated vouchers supplied by HFS foral eligible survivors for whom hospital emergency services were provided pursuant to its approved Treatment Plan. 1. "Voucher" means a document generated by a hospital at the time the sexual assault survivor received hospital emergency and forensic services that a sexual assault survivor may present to ‘providers for follow-up healthcare. 2. Every treating hospital providing hospital emergency and forensic services to sexual assault survivors shall issue a voucher to any sexual assault survivor who is cligible to receive one. Emergency Department managementsaffand clinically trainedstafftaking careof assault victims ‘shall register victims within the HFS MEDI system. Vouchers willbeprintedand given with ‘explanationofuse tothe victim. The hospital shall make a copyof the voucher to the sexual assault survivor afte discharge wpa request. 3. Ifa sexual assault survivor is covered by one or more policies of health insurance o is a beneficiary under publico private health coverage program the hospital shall bill he insurance company or program. With respect to such insured patents, applicable deducibi, co-pay, co￾insurance, dis] of lam o any other out-of-pocket insurance-related expense may be submitted to the Ulinois Sexual Assault Emergency Treatment Program as full payment. If a sexual assault survivor is neither eligible to receive benefits under the medical assistance program under Article V ofthe Public Aid Code nor covered by a policy of reimbursement o the llinois Sexual Assault Emergency Treatment Program under the DepartmenofHealthcare and Family Services® allowable ratsunderth Ilinois Public Aid Code. Ifa sexual assault survivor presents a voucher for follow-up healthcare for the pharmacy that dispenses prescribed medications 10. sexual assault survivor shall submit the requestfo reimbursement for follow-up healthcare, laboratory, or pharmacy services to the Ilinois Sexual Assault Emergency Treatment Program vader the Department of Healthcare and Family Services in accordance with 89 ll. Adm. Code 148.510 at he DepartmentofHealthcare and Family Services’ allowable rates un the linois Public Aid Code. Nothing in this subsection (a) precludes hospitals from providing follow-up healthcare and receiving reimbursement under this Section. The patient wil receive a copyof the noice to sexual assault survivors (attachment B) upon discharge. G. The hospital Medical Records Department shall maintain and preserve althe medical records of survivors who arel yearsofage or oder in a manner and fora duration of20 years afer the date the record was created. The medical recordsof survivors under the age of 18 years must be retained for a periodof 60yearsafer the survivor reaches the age of 18 years. H. Under llinois law, whenever any emergency room personnel have “reasonable cause to believe that a person hs been delivered a controlled substance without his or he conseat”, personnel designated by the hospital have an obligation to act L Ina situation in which a sexual assault vitim may have been administered a dtc-rape drug, the following guidelines will insure that ‘A. Medical personnel will meet their statutory obligations to inform a victim ofthe effects of such drugs,of the victim's right 0 be ested andofthe scopeofsuch est; B. The victim's consent 10 be tested or th presence ofdrugs, if given, wil be fully informed and freely given; and C. Reliable and admissible evidence s collected in case in whicha victim may have been given a dac-rape drug and has given consent 0 be tosid. 1. Evaluation Reasonable Cause to Believe that Someone Has Been Drugged Medical personnel should answer th following questions to determine whether they have reasonable cause to believe that someone my have been given a controlled substance without the victim's consent: ‘A. Docs the victim show signs of being drugged now ori she sill unconscious? B. Docs the victim have difficulty remembering events leading up to her arival at the Hospital? C. Are the circumstances of the assault tht the vieim describes consistent with drugging? For example, did the victim wake up somewhere unknown (0 he or somewhere she doesnt remember going? D. Is there other evidence that the police found a th crime scene that suggests tha th victim ‘may have been drugged? E. No Reasonable Cause: If medical personnel do not have reasonable cause o belcve that the victim was drugged without consent, the medical personnel should as the victimifshe has any reason to believe she was given a controled substance without her consent Ifthe vitim does not have any reason o believe she was drugged, medical personnel should not ask any more questions about controlled substances, should not collect a urine sample for toxicology purposes unless medially indicate for other reasons and should conte with evidence collection asin ny other sexual assault case. F. Reasonable Cause: Ifthe victim or medical personnelhasreasonable causeto believe that3 victim may have been given a controlled substance without consent, then the medical personnel must do the following: 1. Explain to the victim the nature and effects of commonly used controlled substances when being administered. Provide the victim withacopyofthe form entitled, "Date-rape Drug Testing: Your Rights.” This form explains the nature and. impactof date-rape drugs as well as the testing procedure. You may choose to read along out loud with the victim as she goes through the form.Ifyou do not do this, you should explain the material on the form to the victim. Recommended language Tor explaining issues about date-rape drugs includes: a. Date-rape drugs are colorless, tasteless and odorless substances that can casily be slipped into beverages undetected. b. Date-rape drugs are strong relaxants, the effetsof which can be felt 2s soon as 15 minutes afer administration. These effects include blackouts, coma, impaired judgement and lossofcoordination. . Alcohol can intensify the effectsofdae-rape drugs. d. Date-rape drugs may cause memory lossofthe events following ingestion. e. Some date-rape drags remain in the system for a lt as 6-8 hours, 0 itis imperative to collect a urine sample as soon as possible. Inform the victimof the right tobe tested forthe presenceof controlled. substances and the right to refusc such test. & Tell the vitim that is she decides to be tested for the presenceof controlled substances; such atest wil disclose ALL controlled substances, including prescription medication and illegal drugs, as well as over the counter medications and alcohol that she ingested. h. Tell the victim that if she may want tobetested for the presenceofdate￾rape drugs, she should givea urine sampleas soon 2s possible. I. Obtaining the Urine Sample<strong> IF the victim agrees to provide a urine sample; medical personnel should follow the following steps: A. Provide the victim with a sterile urine collection container fo the collectionof the urine. B. Wite the victim's name, the date, and the time the urine s collected on the outside of the container C. Victim's toilet paper to be collected if used befor evidence collection. Give to police department to use for evidence, D. Seal the container with tape and initial and date it to ensure proper evidence packaging and chainofcustody. E. The sealed urine specimen container should not be placed inside the evidence collection kit atany time. IV. Completing the Consent to Toxicology Form A. The victim can voluntarily decide to be tested forthe presence of drags in their system. Such a test wll disclose the following substances, whether ingested voluntarily or involuntarily, controlled substances (including prescription medications and ilegal drugs), over the counter medications and alcohol. B. Once the urine sample i collected, medical personnel should refer to the "Consent fo Toxicology” (Attachment 1)form. This is a three-part form that has an original top copy and three carbon copies, allofwhicharedifferent colors. Forms should be available at all hospitals that are treatment hospitals for sexual assault victimspursuant o the Sexual Assault Survivors Emergency Treatment Act 41 0 ILCS 70/1 el. Seq. for additional forms, contact the Program Administratorofthe Sexual Assault Evidence Collection Kitof the inois State Police at (217) 782-4975. C. Medical personnel should complete the top sectionofthe form indicating the name of the victim and the date and time that the urine sample was provided. D. The victim should choose and sign Option A to release and have your sample teed. Testing wil be conducted at a forensic laboratory. A witness (preferably medical personnel) must also sign the form. Ifyou choose to have your sample collected and held, select and initial Option B. Your sample will be collected and released to law enforcement. No testing wil be conducted. Law enforcement will hold your urine sample for a minimum of 10 years orunil the victim's 28th birthday,ifthe victim is under the ageof 18. E. The law enforcement officer should complete the receiptofevidence portionofthe: “Consent to Toxicology” form. F. The Law enforcement officer should then tearoffthe individual copies the "Consent to Toxicology" form and give the appropriate copies to the hospital, the victim, keep the law enforcement copy, and take the laboratory copy to the llnois State Police Forensic Science Laboratory with the tine sample. V. Documentation</strong> A. The hospital medical record will include th following information: 1. Offer photo documentation and obiain consent to take photos. Digital photos and/or colposcope video will be stored and backed up securely in original fle format. 2. Indicate whether the llinois Stat Police Sexual Assault Evideace Collection Kit ‘was completed. 3. Indicate whethera report was filed with the DepartmentofChildren and Family Services, or whether the Department on Aging or the DepartmentofPublic Health was contacted, 4. Indicate the presenceofany and all persons during the examination process. . Include brief, general information concerning possible injury; drug allergies; and, for female patients, adetailed gynecological history, including: whether the patient Knows or believes that she is pregnant, historyofprior gynecological surgery such as hysterectomy or tubal ligation, historyof contraceptive use, historyofcancer, and any prior genital injury or trauma. 6. Indicate presenceofall indications of trauma, major or minor, that may be used in a criminal proceeding (e.g, cuts, scratches, bruises, red marks, any minor signs or trauma). 7. Indicateifth sexual assault survivor changed clothes, bathed or douched, defecated, urinated, ate, smoked, or performed oral hygiene between the time ofthe sexual assault and the time ofthe examination B. The medical record shall not reflect any conclusions regarding whether acrime (c.g. criminal sexual assault, criminal sexual abuse) occurred. VL Education/Training A. In order to provide competent and up-to-date treatment to the sexual assault survivor, all ED nurses and providers will receive a minimumof two hoursofcontinuing education on responding o sexual assault survivors every two years as defined by Ilinois Department of Health IReznik, Sandra E. "Plan B: How It Works" HealthProgress 91, n0 1 2010) Attachment B NOTICE TO SEXUAL ASSAULT SURVIVORS KEEP THIS INFORMATION—YOU MAY NEED ITLATER TREATMENT HOSPITAL NAME: __FRANCISCAN HEALTH OLYMPIA FIELDS 5 ee Sopa - ‘professional,laboratory,orpharmacyforhospitalemergencyservicesorevidencecollectionintheemergency department. Ifyouhaveinsurance,yourinsurancewillbebilled,butyouare notresponsible foranydeductible orco-payrelatedtotheseservices. 2. Voucher —Befoe leavingtheem: departmentofthefacilitythattreatedyou,the hospital will give yuan Ruthorzaton for Fiyment autho ooo up eaheaes you are Sngble 1 ereive one ou ze igh for voucherif you re no covered by Medic you we ovared by MA,Mediaia will uy fr ‘your follow-up treatment, so you should present your Medicaid card to the follow-up provider. If you have follow-up healthcarevisitsrelated 10 the sexualassault, including but not limited to counseling, lab tests and medications, the voucher allows you to get services at no charge to youfor 90days following the initial hospital emergency visit. Give the voucher to the follow-up healthcare provider and ask him or her 07KYOU 4 Cop Bo ot BNE OoYou ent Flows row. ou oy ae Be phfo copy from your medical record. 3. “Follow-up healthcare” —means healthcare services related to sexual assault, including laboratory and pharmacy services, provided within 90 daysofyour initial visit for hospital emergency services. 4. Numberto CallIfYouReceivedaRelatedHospitalBill—You may call this numberif you receive a bill From Eh hmAal fo hose ergoshoe of vescollin services rAd toe Sol asst 1-866-865-0363. You should not have received a bill, the hospital will make the necessary adjustments. S. Number toCallIfYou RecsveaRelated Bl trom a Health Care Professions Labor Pharmacy 16you eceve a UT fom an ambulance provider, besaprofisonel, a boaror pharmacy tht related to the sexual assault, you may call this toll-free numberofthe office ofthe [llinois Attomey General, Crime Victim Services Division: 1-800-228-3368 (Voice); 1-877-398-1130 (TTY) 6. Inpatient Services vou ars afited othe Hola 5 a tet, you my be ile fr ioptint ‘services provided by a hospital, health care professional, laboratory, or pharmacy. ®Ifyou have insurance coverage, your insurance company will be billed and you may be responsible for ry Copa, deducibleooaeumsteed bp Jou Ante compees ®Ifyou have no insurance, you may be eligible for discount under the Hospital Uninsured Patient Dikcomi Act ® To find outif you are eligible for financial help under the Crime Victim Compensation Act, contact the Officeofthe Illinois Attomey General, Crime Victim Services Division at 1-800-228-3368 (Voice); FETs (rT (VOTE: The ormation in #6 apples olif os were admitted othe bspital aan intent 7. Rape CrisisAdvosates — Ifyou need ssistance with anyofthe ove tems, contet local ap crisis cee, Rapecrisis centersprovide free legal and medical advocacy. Patent Signature oo Date Fr Franciscan HEALTH PATIENT LABEL MUST BE Olympia Fields PLACED WITHIN THIS BOX NOTICE TO SEXUAL ASSAULT SURVIVORS 35100157 Rev. 1016,8/17, 1015 Pagel of1 Discharge Instruction  Policy Number: ER-119 Section: Emergency Department PURPOSE: To provide comprehensive acute care, treatment, evidence collection, appropriate referral for follow-up care, counseling, and comprehensive documentation for all adulladolescen sexual assault victims in accordance with Sexual Assault Survivors Emergency Treatment Code (77 ILL Adm. Codes 545). Prepubescent pediatric victims willbe transferred in accordance to an agreed upon contractual facility with an accepting physician and/or SANE nurse. PROCEDURE: A. Notify appropriate police department and Y.W.C.A.R ES. or the hospital Social Service: representative. B. The Emergency Department nurses will render comprehensive competent care: 1. A member ofthe health care team shall respond within minutes to movethe survivor to a closed environment to ensure privacy. Health care personnel shall refer to survivors by code to avoid embarrassment 2. The hospital shal offer to call a friend or family member. The rape crisis advocate will be called 0 accompany the survivor. 3. Conduct a swif initial assessmentof the needs and support required preventing further trauma. 4. Provide prompt reatment for physical injury and evidence collection within a private environment, with only examining health care personnel, any translator needed and, if indicated (with consentof survivor) a specially trained advocate and one support person of the survivors choosing,ifrequested. 5. Facilitate appropriate follow-up care with a physician licensed to practice medicine in all of its branches as provided in Medical Practice Act of 1987. Payment voucher 0be: provided to eligible patients. 6. Recognize special diagnostic and therapeutic needsof the sexually assaulted and arrange for appropriate care on case by case basis ~ (refer (0 attached procedure "Toxicology Screen for date-rape victims’. 7. The hospital wil provide emergency contraception information and treatment in accordance with IDPH Section $45.35.1 Each survivor of sexual assault will receive medically and factually accurate oral and written information about emergency contraception as soon as possible andcan be administer within 96 hours. Whena survivor presents herselfat the hospital for emergency treatment services; the indications and contraindications and risks associated with the useofemergency contraception; anda descriptionof how and when survivors will be provided emergency contraception upon the writen order ofa physician licensed to practice medicine. A female survivorofsexuzl assault wha shows a negative result fo pregnancy and whose history corresponds to this will be offered an emergency contraceplive intervention. If the sexual assault survivor accepts this treatment, the emergency contraceptive willbeprovidedin the emergency department the survivor presentsa positive result on th tests, the survivorwill be counseled that the emergency department will not offer the formulation. Ifthe test is positive fo pregnancy, the sexual assault survivor will be counseled tht thi pregnancy is not of immediate or recent origin. CLINICAL APPLICATION C. Evidence/Specimen Collection 1. Follow current protocols for evidence collection kits provided by the Stateof Ilinois. An offer to complete a Sexual Assault Evidence Collection kit for any sexual assault survivor who presents within a minimum ofthe Jas 7 daysof the assault or who has disclosed past sexual assaultby a specificindividualand wasin the careof that individual within a ‘minicomofthe last 7 days. 2. Obtain consent for treatment, consent for photos, and for releaseofevidence from the. patient, thus insuring all information and cvidence may be released to the appropriate law enforcement agency. 3. Ifthe case of a survivor wha is a minor 13 yearsofage or older, evidence and information conceming the sexual assault may be released at the written consentofthe minor. If the survivor is a minor whoi less than 13 years ofage, or prepubescent evidence and information concerning the sexual assault may be released at the written consentofthe parent, guardian, investigating law enforcement officeror Department ofChildren and Family Services. Ifthe survivor is anadultwho has aguardianofthe person, ahealth care surrogate, or an agent acting under the health care power of attomey, then consentofthe guardian, sumogate, or agent i not required (0 release evidence and information concerning the sexual assault. Ifthe adult is unable o provide consent for the release of evidence and information and a guardian, surrogate, or agen! under a health care power of attomey is unavailable or unwilling to release the information, then an investigating law enforcement officer may authorize the release. 4. Photographs of indicationsof traumamaybe taken for evidentiary purposes with the ‘written consentofthe sexual assault survivorof the survivors parent or guardianif the survivor is less than 13 yearsof age, or prepubescent. If the survivor is less thanl 3 years of age, or prepubescent and the parent or guardian is not immediately available, photographs ‘may be taken and shall be released to law enforcement personnel and State's Attomey staff ‘when written consent is obtainedfrom a paren, guardian, o law enforcement office, oF the DepartmentofChildren and Family Services 5. Complete all required forms and distribute as instructed in the kit. 6. Rechecktht ll specimensarc labeled andscaled with appropriate tap. All specimens must be labeled with: a. Exact source of the specimen b. Patient name c. Nameofperson collecting the specimens d. Date and time specimens collected 2. Offer patient a shower aftr evidence collection is completed. 8. As soon as practical, but in no event more than 4 hours ater the completion of medical forensic services, the hospital shall make reasonable efforts o detecanine the law enforcement ageney having jurisdiction where the assault occurred, contact said agency and noify that the hospital is in posscssionofsexual assault evidence and the date and time the collection was completed. This notification date and time and name ofnotified shall be documented in the medical record. 9. Ifthe law enforcement agency having jurisdiction has not taken physical custodyofthe sexual assault evidence within § daysofthe first contact by the hospital, the hospital hall renolify the agency and document as such in the medical record. 10. Ifthe law enforcement agency having jurisdiction has not takenphysical custody ofthe sexual assault evidence within 10 daysof the initial contact by the hospital, the hospital shall contact the State's Attorneyofthe county where the law enforcement agency having jurisdiction is located to report the possession ofevidence,dateandtime of collection, the law enforcement agency having jurisdiction and date, ime and names of persons notified at said agency. This notification shall be made within 14 daysofthe collection of the sexual assault evidence. n The kits to be kept In a secure locked place until released to legal authority ‘maintaining chainofcustody. The officer accepting custody must sign the appropriate forms as well a theevidencekit itself. D. Treatment 1. Treatment should include the following: care of physical injuries, preventionofsexually transmitted diseases and anticipationofpsychological consequences. 2. Laboratory Examinationof assaulted victim should include, but not be limited to: Beta HCG (beta human chorionic gonadotropin level), VDRL, hepaits panelacuteand rapid HIV screening, or any additional test ordered by the Emergency Department physician. 3. Ifa STD is suspected or confirmed, the patient will receive the proper medication. In addition, the victim will be given a prescription fo follow-up treatment, when necessary. 4. HIV prophylaxis shallbeexplained and offered to victims presenting within72 hours of assault as deemed appropriate by the attending physician, advanced practice nurse or physician assistant in accordance with CDC guidelines. Ifaccepted by the victim, an initial dose shall be offered at the hospital with a prescription for the remaining regimen given. E. Discharge 1. Thepatient will be instructed (0 seek follow-upcarewith their personal physician.Ifthe patient does not have a personal physician, she/he will be given follow-up information according to protocol. The patient will be instructed to followup within 24 — 48 hours after their visit to the Emergency Center. 2. The sexual assault survivor will receive information and follow-up referrals a appropriate, to maximize recovery. Rape Hotline 1-600-656 HOPE (4473) South Suburban Family Shelter, Inc. (708) 335-4125 YWCA Metropolitan Committee against Rape ‘Suburban District 24 hours a day (708) 74-5672 ‘The Emergency Department registered nurse is responsible for providing appropriate ltrature such as: 1. "After sexual assault” 2. Crime Victims" Social Services or a representative from Y.W.C.AR.E.S may assist with the support process. F. Sexual assault survivors shall be informedoftheir rights under the Victims of Violent Crimes& Compensation Act. Accordingly, the hospital shall provide emergency servicesa no direct charge to the survivor,Ifthe survivor is neither eligible to receive services under the llnois Public Aid Code nor covered by a policy ofinsurance, the hospital shal seek reimbursement only from the Iiinois Department of Healthcare and Family Services (HFS), according to procedures established by HFS for thal purpose (Hospital Services, §9 ILL. Admin. Code 148). The hospital shall submit billings to HFS or properly. authenticated vouchers supplied by HFS forall eligible survivors for whom hospital emergency services wee provided pursuant to its approved Treatment Plan. 1. "Voucher" means a document generated bya hospital at the time the scxual assault survivor received hospital emergency and forensic services that sexual assault survivor may presen to providers for follow-up healthcare. 2. Every treating hospital providing hospital emergency and forensic services to sexual assault survivors shall issue a voucher to any sexual assault survivor who s eligible o receive one. Emergency Department managementstaff and clinically trainedstafftaking careofassault victims shall register victims within the HFS MEDI system. Vouchers will beprintedand given with explanation ofuse to the victim. The hospital shall make a copyof the voucher o the sexual assault survivor afer discharge upon request 3. Ifa sexual assault survivor is covered by one or more policiesof health insurance or is a beneficiary under public or private health coverage program the hospital shall bil the insurance. ‘company or program. With respect to such insured patients, applicable deductible, co-pay, co￾insurance, denialof claim or any other out-of-pocke! insurance-relted expense may be submitted to the Ilinois Sexual Assault Emergency Treatment Program as full payment. Ifa sexual assault survivor is neither eligible to receive benefits under the medical assistance program under Asticle Vofthe Public Aid Code nor covered bya policy ofreimbursement to the Ilinois Sexual Assault Emergency Treatment Program under the Department of Healthcare and Family Services’ allowable rates under the Illinois Public Aid Code. Ia sexual assault survivor presents a voucher for follow-up healthcare forthe pharmacy tha dispenses prescribed medications 0a sexual assault survivor shall submit the request for reimbursement for follow-up healthcare, laboratory, or pharmacy services to the llinois Sexual Assault Emergency Treatment Program under the DepartmentofHealthcare and Family Services in accordancewith§9 Il. Adm. Code 148.510 at the DepartmentofHealthcare and Family Services’ allowable rates un the Ilinois Public Aid Code. Nothing in this subscction (3) precludes hospitals from providing follow-up healihcare and receiving reimbursement under this Section. The patient will receiveacopyofthe notice to sexual assault survivors (attachment B) upon discharge. G. The hospital Medical Records Department shall maintain and preserve all the medical records of survivors who arel 8 yearsof age or older in a manner and fora duration of20 years afer th date the record was created. The medical records ofsurvivors under the age of 18 years mustberetained fora periodof60 years afte the survivor reaches the age of 18 years. H. Under Iinois law, whenever any emergency room personnel have “reasonable cause to believe that a person has been delivered a controlled substance without his or her consent’, personnel designated by the hospital have an obligation 0 act. 1 Ina situation in whicha sexual assault victim may have been administereda date-rape drug, the following guidelines will insure that: A Medical personel will meet thei statutory obligations (0 informa victim ofthe effects of such drugs, ofthe vitiny's right {0 be ested andofthe scope of such tes; B. Thevitin's consent tobe ested for the presenceofdrugs, if given,willbe fully informed and freely given; and C. Reliable and admissible evidence is collected in cases in whicha victim may have been given adale-rapedrug and has given consent 0 be ested. IL. Evaluation Reasonable Cause to Believe that Someone Has Been Drugged Medical personnel should answer the following questions to determine whether they have reasonable cause to believe that someone may have been given a controlled substance without the: victim's consent: ‘A. Docs the victim show signsofbeing drugged now of is she still unconscious? B. Docs the victim have difficulty remembering events leading up ther arrivala the hospital? C. Are the circumstancesofthe assault that the victim describes consistent with drugging? For example, did the victim wake up somewhere unknown to her or somewhere she doesnt remember going? 1D. Is there other evidence that the police found at the crime scene that suggests that the victim may have been drugged? E. No Reasonable Cause: Ifmedical personnel do not have reasonable cause to believe that the victim was drugged without consent, the medical personnel shoulda the victimifshe: has any reason to belicve she was given a controlled substance without her consent. Ifthe victim does not have any reason to believe she was drugged, medical personnel should not ask any more questions about controlled substances, should not collect a urine sample for toxicology purposes unless medically indicated for other reasons and should continue with evidence collection asin any other sexual assault case. F. Reasonable Cause:Ifthe victim or medical personnel has reasonable cause to believe that a victim may have been given a controlled substance without consent, then the medical personnel must do the following: 1. Explain to the victim the nature and effectsofcommonly used controlled substances when being administered. Provide the victim with a copyofthe form entitled, "Date-rape Drug Testing: Your Rights." This form explains the nature and. impactof date-rape drugs as well asthe tesing procedure. You may choose to read along out loud with the victim as she goes through th form. Ifyou do not do this, you should explain the material on the form to the victim. Recommended language for explaining issues about date-rape drugs includes: a. Date-rape drugs are colorless, tasteless and odorless substances that can easily be slipped into beverages undetected. b. Date-rape drugs are strong relaxants, the effects of which can be felt as soon as 1 minutes afer administration.Theseeffects include blackouts, coma, impaired judgement and lossofcoordination. . Alcohol can intensify th effects of date-rape drugs. d. Daterape drugs may cause memory lossofthe events following ingestion. e. Some date-sape drugs remain in the system for a litle as 6-8 hours, so it is imperative to collect urine sample as soon as possible. Inform the victimofthe right to be tested for the presence ofcontrolled. substances and the right o refuse such test g. Tell the victim that is she decides to be testedfor the presenceofcontrolled substances; sucha test wil disclose ALL controlled substances, including prescription medication and illegal drugs, as well as over the counter ‘medications and alcohol that she ingested. h. Tell the victim thatif she may want o be tested for the presenceofdatc￾rapedrugs,she shouldgive a rine sample as soon as possible. I. Obaining the Urine Semple<strong> Ifthe victim agrees to providea urine sample; medical personnel should follow the following. steps: A. Provide the victim with asterile urine collection container for the collection ofthe urine. B. Write the victin's name, the date, and the time the urine is collected on the outside of the container. C. Victim's toilet paper to be collectedifused before evidence collection. Give to police department to use for evidence. D. Seal the container with tape and initial and date t to ensure proper evidence packaging and chainof custody. E. The sealed urine specimen container should not be placed inside the evidence collection kit at any time. IV. Completing the Consent to Toxicology Form A. The vietim can voluntarily decide to be tested for the presenceofdrugs in their system. Sucha test will disclose the following substances, whether ingested voluntarily or involuntarily, controlled substances including prescription medications and illegal drugs), over the counter medications and alcohol B. Once the urine sample is collected, medical personnel should refer tthe “Consent to Toxicology" (Atiachment 1) form. This is a three-part form thathasan original top copy and three carbon copies, allof which are different colors. Forms should be availableat all hospital that are treatment hospitals for sexual assault victims pursuant o the Sexual Assault Survivors Emergency Treatment Act 41 0 ILCS 70/1 et. Seq for additional forms, contac the Program Administratorofthe Sexual Assault Evidence Collection Kitof the iinois State Police at 217) 782-4975. C. Medical personnel should complete the top sectionofthe form indicating the name of the victim and the date and time that the urine sample was provided. 1D. The vietim should choose and sign Option A to release and have your sample tested. Testing will be conducted at forensic aboratory.A witness (preferably medical personnel) must also sign the form.Ifyou choose to have your sample collcted and held, select and inital Option B. Your sample will be collected and released to law enforcemea. No testing wil beconducted. Law enforcement will hold your urine sample fora minimum Of 10 years or nti the victin's 28h birthday, if the victim is under the age of 13. E. The law enforcement officer should comple the receiptofevidence portion of the “Consent to Toxicology” form. F. The Law enforcement officer should then tear off he individual copies the "Consent to Toxicology” form and give the appropriate copies o the hospital, th victim, keep the aw enforcement copy, and take the laboratory copy to the Tlinois State Police Forensic Science Laboratory with the urine sample. V. Documentation</strong> A. The hospital medical record will include the following information: 1. Offer photo documentation and oblain consent {0 ake photos. Digital photos and/or colposcope video will be stored and backed up securely in original file forma. 2. Indicate whether te Ilinos State Police Sexual Assault Evidence Collestion Kit was completed. 3. Indicate whether a eport was filed with the DepartmentofChildren and Family Services, or whether the Department on Aging or the Department of Public Health was contacted. 4. Indicate the presenceofany and al persons during the examination process. 5. Include brief, general information conceming possible injury; drug allergies; and, for female patients,a detailed gynecological history, including: whether the patient knows or believes that she is pregnant, historyofprior gynecological surgery such as hysterectomy or tubal ligation, historyofcontraceptive use, history ofcancer, and any prior genital injury of trauma. 6. Indicate presence of all indications oftrauma, major or minor, that may be used in a criminal proceeding (e.g. cuts, scratches, bruises, ed marks, any minor signs or trauma). 7. Indicate if the sexual assault survivor changed clothes, bathedordouched, defecated, urinated, atc, smoked, or performed oral hygiene between the time of the sexual assault and the timeof the examination. B. The medical record shall not reflect any conclusions regarding whether a crime (c.g. criminal sexual assault, criminal sexual abuse) occurred VL Education/Training A. Tn order to provide competent and up-to-date treatment o the sexual assault survivar, all ED nurses and providers will receive « minimumof two hours ofcontinuing education on responding 10 sexual assault survivors every two years as defined by Ilinois Department of Health, IReznik, SandraE. “Plan B: How It Works" Health Progress 91,10 1 (2010) SIU SCHOOL of MEDICINE [2 Hlinois Sexual Assault and Medical Forensic Services 2-hour Training StartsOn: Fr, 1/3/2020 Com $000 0 1200 AM na Ende om Sun. 122002 | 11:45 PM Type: Inlemet Activity Enduring Material Croatar2 sip sts Description: The flinois pretest * a a] = Forensic Services 2-hour to continue Training is being provided by yoo " the Office ofthe linois Atomey General SANE posttest x Program to meet the mandatory continuing Biatisbo * education requirement for responding to sexual assault survivors as addressed in the ‘Soxual Assault Sunvvors Emergency Trealment Act (410 ILCs 7012) Not included in tis raining. but also required by the law. is information on the hospitals sexual assaul.wlaled policies and procedures. Please make sure to check wih your hospital regarding these additional requirements 2