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

PART B

1.         Attach copies of appropriate documents distributed to 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 the medication.

d)         Necessity of follow-up visits, examinations and laboratory tests.

e)         Information concerning emergency contraception in accordance with Section 545.95 of the Regulations. 

f)          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.)

g)         Drug-facilitated sexual assault testing information, including an explanation of the comprehensive scope of drug screening and the limited time frame within which evidence can be collected.

2.         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.   

3.         Describe counseling resources provided to 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 hospitals providing treatment services to sexual assault survivors.  These conditions are enumerated below to ensure that all treatment hospitals 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 sexual assault survivors, with the consent of the sexual assault survivor and as ordered by the attending physician, advanced practice nurse or physician assistant in accordance with the Sexual Assault Survivors Emergency Treatment Act and with the Sexual Assault Survivors Emergency Treatment Code (see Section 545.60 of the Regulations).

2.         The hospital shall provide emergency services at no direct charge to the survivor.  If the survivor is neither eligible to receive services under the Illinois Public Aid Code nor covered by a policy of insurance, the hospital shall seek reimbursement only from the Illinois Department of Healthcare and Family Services (HFS), according to procedures established by HFS for that purpose (Hospital Services, 89 Ill. Adm. Code 148).

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

4.         The hospital shall maintain and preserve all survivor medical records in a manner and for a duration established by hospital policy 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].

(Source:  Amended at 33 Ill. Reg. 14588, effective October 9, 2009)