II 114th CONGRESS 2d Session S. 2948 IN THE SENATE OF THE UNITED STATES May 18, 2016 Mrs. Murray (for herself, Mrs. Shaheen , Mrs. McCaskill , Mrs. Gillibrand , Ms. Baldwin , Mrs. Boxer , Mr. Blumenthal , Mr. Bennet , and Mr. Wyden ) introduced the following bill; which was read twice and referred to the Committee on Health, Education, Labor, and Pensions A BILL To plan, develop, and make recommendations to increase access to sexual assault examinations for survivors by holding hospitals accountable and supporting the providers that serve them.

1. Short title This Act may be cited as the Survivors’ Access to Supportive Care Act or SASCA . 2. Purpose It is the purpose of this Act to increase access to medical forensic sexual assault examinations and treatment provided by sexual assault forensic examiners for survivors by identifying and addressing gaps in obtaining those services. 3. Definitions In this Act: (a) Terms relating to GAO report In this Act, the following terms shall, with respect to hospitals that receive Federal funds, have the meanings given such terms in the report of the Government Accountability Office entitled Information on Training, Funding, and the Availability of Forensic Examiners (GAO–16–334: Published: Mar 18, 2016): (1) MFE The term medical forensic examination or MFE . (2) SAFE The term sexual assault forensic examiner or SAFE . (3) SANE The term sexual assault nurse examiner or SANE . (4) SART The term sexual assault response team or SART . (b) Other terms In this Act: (1) Secretary The term Secretary means the Secretary of Health and Human Services. (2) Sexual assault The term sexual assault has the meaning given such term by the Federal Bureau of Investigation in the Uniform Crime Reporting Program’s Summary Reporting System. I Strengthening the Sexual Assault Examiner Workforce 101. Understanding sexual assault care (a) Purpose It is the purpose of this section to identify areas for improvement in health care delivery systems providing services to survivors of sexual assault. (b) Grants The Secretary may award grants to State governments for the development and implementation of State surveys on health care provider access for sexual assault forensic examination services to identify— (1) State requirements, minimum standards, and protocols for training sexual assault examiners; (2) State requirements, minimum standards, and protocols for training non-SANE/SAFE emergency services personnel involved in sexual assault medical forensic examinations; (3) the availability of, and patient access to, trained SAFE, SANE, and other providers who perform such examinations; (4) regional, provider, or other barriers to access sexual assault care and services; (5) the dedicated Federal and State funding to support SAFE/SANE training; (6) funding opportunities for SANE/SAFE training and continuing education; (7) billing and reimbursement practices for medical forensic examinations including private health insurance, Medicare, Medicaid, the State’s victims compensation program and any other crime funding or special sources of funding that contribute to payment for such examinations; (8) an assessment of which hospitals and States are not in compliance with Federal law, are not providing survivors of sexual assault for their medical forensic examination or sexual assault examination, and which are billing such survivors for such services; and (9) the availability of SAFE/SANE training, frequency of which training is convened, the providers of such training, what (if any) is the State’s role in such training, and what process or procedures are in place for continuing education of such examiners. (c) Eligibility To be eligible to receive a grant under this section, an entity shall— (1) be a State with public, private, and non-profit hospitals that receive Federal funding; and (2) submit to the Secretary an application through a competitive process to be determined by the Secretary. (d) Public dissemination and campaign (1) Public availability The results of the surveys conducted under grants under this section shall be published by the Secretary on the Internet website of the Department of Health and Human Services on a biennial basis. (2) Campaigns An entity that receives a grant under this section shall— (A) make the findings of the survey conducted under the grant public; (B) develop policies, best practices recommendations, and an action plan to increase access to SAFE/SANE; and (C) utilize such findings to develop and implement a public awareness campaign to improve patient access to services and providers, and improve hospital and stakeholder practices, with respect to sexual assault forensic examinations. (e) Authorization of appropriations There is authorized to be appropriated to carry out this section, $2,000,000 for each of fiscal years 2017 through 2019. 102. Improving and strengthening the sexual assault examiner workforce pilot program (a) Purpose It is the purpose of this section to establish a pilot program to develop, test, and implement SAFE training which expands the availability of SAFE, SANE, and SART providers for survivors of sexual assault. (b) Eligibility To Provide services With respect to hospitals that receive Federal funds, SAFE/SANE services, and other forensic medical examiner services shall be provided by health care providers who are also one of the following: (1) A physician, including a resident physician. (2) A nurse practitioner. (3) A nurse midwife. (4) A physician assistant. (5) A certified nurse specialist. (6) A registered nurse. (7) Where a provider of the type described in paragraphs (1) through (6) is not available, such services may be provided by an individual who has completed sexual assault forensic examiner training and maintained continuing education in such training, as developed by the Secretary and the Task Force under section 201. (c) Training and continuing education (1) Establishment (A) In general Not later than 1 year after the date of enactment of this Act, the Secretary, in consultation with the Attorney General, the Centers for Medicare & Medicaid Services, the Centers for Disease Control and Prevention, the Health Resources and Services Administration, the Indian Health Service, the Office for Victims of Crime, the Office on Women’s Health, and the Department of Justice Office on Violence Against Women, and with input from national experts such as the International Association of Forensic Nurses, the Emergency Nurses Association, the Rape, Abuse, and Incest National Network, the National Alliance to End Sexual Violence, the National Sexual Violence Resource Center, and others shall— (i) establish a national continuing and clinical education pilot program for SAFEs, SANEs, and other individuals who perform such examinations; and (ii) develop, pilot, implement, and update as appropriate continuing and clinical education program modules, webinars, and programs for all hospitals and providers to increase access to SANE and SAFE services and address ongoing competency issues in SAFE/SANE practice of care. (B) Application The training and continuing education program established under subparagraph (A) shall be available to all SAFEs, SANEs, and other providers employed by, or any individual providing services through, facilities that receive Federal funding. (2) Elements The training and continuing education program established under this subsection shall require that the provision of training in sexual assault medical forensic examinations be provided by qualified personnel who possess— (A) the minimum training required to be considered a SAFE/SAFE described in paragraph (1); or (B) training and clinical or forensic experience in sexual assault forensic examinations similar to that required for a certification described in subparagraph (A) based in part on the recommendations of the National Sexual Assault Forensic Examination Training Standards issued by the Department of Justice on Violence Against Women. (3) Nature of training The training provided under the training and clinical and continuing education program established under this subsection shall incorporate and reflect current best practices and standards on sexual assault medical forensic examinations consistent with the purpose described in section 2, such as the use of telemedicine consistent with section 201. (4) Applicability of training requirements (A) In general Effective beginning 1 year after the date of the enactment of this Act, a licensed medical professional shall not provide SAFE/SANE services, or provide any other forensic medical examiner services, unless the professional has completed— (i) all training required under the training and continuing education pilot program established in this subsection; (ii) all training required to be considered a SANE by the International Association of Forensic Nurses; or (iii) all training required to be certified or credentialed as a SAFE/SANE by the applicable State issuing body. (B) Continued application of clinical education and training If a practicing SAFE/SANE was qualified or trained through a practical training program (such as the International Association of Forensic Nurses SANE training) prior to the date of enactment of this Act, such examiner shall be permitted to continue to provide services as a SAFE or SANE so long as such examiner meets the applicable continuing clinical education requirements. (C) Rule of construction Nothing in this Act (or the amendments made by this Act) shall be construed to preempt any provision of Federal or State law to the extent that such Federal or State law provides protections for survivor’s access to SAFE/SANE care that are greater than the protections provided for in this Act (or amendments). (5) Effective date (A) In general The pilot program established under this section shall terminate on the date that is 2 years after the date of such establishment. (B) Authority for modifications Upon the expiration of the pilot program as provided for in subparagraph (A), the Secretary may implement modifications relating to training and continuing education requirements based on such program to increase access to SANE and SAFE services for survivors of sexual assault. (C) Technical assistance The Secretary and the Attorney General shall provide technical assistance and guidance to ensure compliance with the requirements of this section. (D) Preemption Nothing in this section shall be construed to preempt any provision of Federal or State law to the extent that such Federal or State law provides protections for survivors of sexual assault that are greater than the protections provided for in this section. 103. National report on sexual assault services in our nation’s health system (a) In general Not later than 1 year after the date of enactment of this Act, and annually thereafter, the Agency for Healthcare Research and Quality, in consultation with the Centers for Medicare & Medicaid Services, the Centers for Disease Control and Prevention, the Health Resources and Services Administration, the Indian Health Service, the Office for Victims of Crime, the Office on Women’s Health, and the Office of Violence Against Women of the Department of Justice (hereafter referred to in this section collectively as the Agencies ), shall submit to the Secretary a report of existing Federal and State practices relating to SAFEs, SANEs, and others who perform such examinations which reflects the findings of the surveys developed under section 101. (b) Core competencies In conducting activities under this section, the Agencies shall address SAFE/SANE competencies including— (1) providing comprehensive medical care to sexual assault patients; (2) demonstrating the ability to conduct a medical forensic examination to include an evaluation for evidence collection; (3) showing compassion and sensitivity towards survivors of sexual assault; (4) testifying in Federal, State, local, and tribal courts; and (5) other competencies as determined appropriate by the Agencies. (c) Publication (1) AHRQ The Agency for Healthcare Research and Quality shall establish, maintain, and publish on the Internet website of the Department of Health and Human Services an online public map of SAFE, SANE, and other forensic medical examiners available to the Department of Health and Human Services. (2) States A State that receives Federal funds shall maintain and make available a State map displaying the number of available SAFE/SANE programs and other forensic medical examiners. 104. Hospital reporting Not later than 1 year after the date of enactment of this Act, and annually thereafter, a hospital that receives Federal funds shall submit to the Secretary a report that identifies the level of community access provided by the hospital to trained SAFEs, SARTs, SANEs, and others who perform such examinations. Such report shall describe— (1) the number of sexual assault forensic examinations done in the hospital in the year for which the report is being prepared; (2) the training that such SAFEs/SANEs undergo, both initially and for recertification; (3) the number of SAFEs/SANEs employed by the hospital, differentiating between part-time and full-time employees; and (4) the SAFE/SANE standards of care applied by the hospital. II Standards of care 201. National Sexual Assault Care and Treatment Task Force (a) Establishment The Secretary shall establish a task force to be known as the SASCA Task Force (referred to in this section as the Task Force ) to review State guidelines, procedures, practices, training, and employment and retention data for SAFE/SANE and other forensic medical examiners. (b) Appointments The Secretary, in consultation with the Centers for Medicare & Medicaid Services, the Centers for Disease Control and Prevention, the Health Resources and Services Administration, the Indian Health Service, the Office for Victims of Crime, the Office on Women’s Health, and the Department of Justice Office on Violence Against Women, and key stakeholders such as the International Association of Forensic Nurses, the Rape, Abuse, and Incest National Network, the National Domestic Violence Hotline, the National Alliance to End Sexual Violence, the National Sexual Violence Resource Center, and community-based organizations shall appoint experts to the Task Force. (c) Objectives To assist and standardize State-level efforts to improve medical forensic evidence collection relating to sexual assault, the Task Force shall— (1) review State-level practices for SAFEs, SARTs, SANEs, and others who perform such examinations to ensure that such practices are consistent with established national training, certification, and practice recommendations; (2) create a best practices guide for forensic medical examiners relating to sexual assault; (3) improve coordination of services, and other protocols regarding the care and treatment of sexual assault survivors and the preservation of evidence between law enforcement officials and health care providers; and (4) update national minimum standards for forensic medical examiner training and forensic medical evidence collection relating to sexual assault. (d) Transparency requirements (1) In general The Task Force shall report to the Secretary, at such time, in such manner, and containing such information as may be specified by the Secretary, on— (A) the recommendation for best practices with respect to improving medical forensic evidence collection relating to sexual assault; and (B) the national minimum standards for medical forensic examinations and treatments relating to sexual assault. (2) Report Not later than one year after the date of enactment of this Act, the Secretary shall submit to Congress a report on the findings and conclusions of the Task Force. (e) Annual summit The Secretary shall convene an annual stakeholder meeting to address gaps in health care provider care relating to sexual assault. Such meetings shall include the Task Force, as well as the Centers for Medicare & Medicaid Services, the Centers for Disease Control and Prevention, the Health Resources and Services Administration, the Indian Health Service, the Office for Victims of Crime, the Office on Women’s Health, and the Department of Justice Office on Violence Against Women, and key stakeholders such as the International Association of Forensic Nurses, the Rape, Abuse, and Incest National Network, National Alliance to End Sexual Violence, National Sexual Violence Resource Center and community-based organizations. 202. Institutes of higher education campus action plan (a) In general Each institution of higher education that receives Federal funds shall make publicly available a written plan of the steps the institution takes to ensure access to sexual assault medical forensic examinations and treatments. Such plan shall include information about the availability of services, and a statement that Federal law requires that such exams be provided free of charge. (b) Access to examinations Each institution of higher education that receives Federal funds shall, to the extent practicable, ensure that students have access to sexual assault medical forensic examination by employing the use of a SAFE/SANE in the campus medical facility or hospital or by entering into a memorandum of understanding or formal agreement with at least one local health care facility to provide such service if no appropriate medical facility is available on campus, including the cost of transportation for students to access services. 203. Expanding access to unified care Part B of title VIII of the Public Health Service Act ( 42 U.S.C. 296j et seq. ) is amended by adding at the end the following: 812. Demonstration grants for sexual assault examiner training programs (a) Establishment of program The Secretary shall establish a demonstration program (referred to in this section as the program ) to award grants to eligible partnered entities for the clinical training of SAFEs/SANEs (including registered nurses, nurse practitioners, nurse midwives, clinical nurse specialists, physician assistants, and physicians) to administer medical forensic examinations and treatments to victims of sexual assault in hospitals, health centers, and other emergency health care service provider settings, including Federally qualified health centers, clinics receiving funding under title X, and other health care providers as determined appropriate by the Secretary. (b) Purpose The purpose of the program is to enable each grant recipient to expand access to SAFE/SANE services by providing new providers with the clinical training necessary to establish and maintain competency in SAFE/SANE services. (c) Grants Under the program, the Secretary shall award 3-year grants to eligible entities that meet the requirements established by the Secretary, for the purpose of operating the SAFE/SANE training programs described in subsection (a) at such entities and to test the provision of such services at new facilities in expanded health care settings. (d) Eligible entities To be eligible to receive a grant under this section, an entity shall— (1) be a rural health care services provider (as defined by the Secretary), a center or clinic under section 330, or a health center receiving assistance under title X, acting in partnership with a high-volume emergency services provider or a hospital currently providing sexual assault medical forensic examinations performed by SANEs or SAFEs, that will use grant funds to— (A) assign rural health care service providers to the high-volume hospitals for clinical practicum hours to qualify such providers as a SAFE/SANE; or (B) assign practitioners at high-volume hospitals to a rural health care services providers to instruct, oversee, and approve clinical practicum hours in the community to be served. (2) submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require, including a description of whether the applicant will provide services under subparagraph (A) or (B) of paragraph (1). (e) Grant amount Each grant awarded under this section shall be in an amount not to exceed $400,000 per year. A grant recipient may carry over funds from 1 fiscal year to the next without obtaining approval from the Secretary. (f) Authorization of appropriations To carry out this section, there is authorized to be appropriated $10,000,000 for each of fiscal years 2016 through 2019. . 204. Technical assistance grants and learning collectives Part B of title VIII of the Public Health Service Act ( 42 U.S.C. 296j et seq. ), as amended by section 203, is further amended by adding at the end the following: 812A. Technical assistance center and regional learning collectives (a) In general The Secretary shall establish a State and provider technical resource center to provide technical assistance to health care providers to increase the quality of, and access to, sexual assault examinations by entering into contracts with national experts (such as the International Forensic Nurses Association and others). (b) Regional learning collectives The Secretary shall convene State and hospital regional learning collectives to assist health care providers and States in sharing best practices, discussing practices, and improving the quality of, and access to, sexual assault examinations. (c) Repository The Secretary shall establish and maintain a secure Internet-based data repository to serve as an online learning collective for State and entity collaborations. An entity receiving a grant under section 812 may use such repository for— (1) technical assistance; and (2) best practice sharing. . 205. Quality strategies The Secretary shall identify SAFE/SANE access and quality in hospitals and other appropriate health care facilities as a national priority for improvement under section 399HH(a)(2) of the Public Health Service Act ( 42 U.S.C. 280j ). 206. Oversight Not later than 1 year after the date of enactment of this Act, the Office of the Inspector General shall issue a report concerning hospital compliance with section 1867 of the Social Security Act ( 42 U.S.C. 1395dd ) and the Violence Against Women Act of 1994 ( 42 U.S.C. 13701 et seq. ) with respect to access to, and reimbursements for, sexual assault medical forensic examinations at the national, State, and individual hospital level. Such report shall address hospital awareness of reimbursements, total reimbursed costs, and any costs for victims.