II 115th CONGRESS 2d Session S. 3203 IN THE SENATE OF THE UNITED STATES July 12, 2018 Mrs. Murray (for herself and Ms. Murkowski ) 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: (1) Community health aide and community health practitioner The terms community health aide and community health practitioner have the meanings within the meaning of section 119 of the Indian Health Care Improvement Act ( 25 U.S.C. 1616l ). (2) MFE The term medical forensic examination or MFE means an examination provided to a sexual assault survivor by medical personnel trained to gather evidence of a sexual assault in a manner suitable for use in a court of law. (3) SAE The term sexual assault examiner or SAE means a registered nurse, advanced practice nurse, physician, or physician assistant specifically trained to provide care to sexual assault forensic examinations. (4) SAFE The term sexual assault forensic examiner or SAFE means a medical practitioner who has specialized forensic training in treating sexual assault survivors and conducting medical forensic examinations. (5) SANE The term sexual assault nurse examiner or SANE means a registered nurse who has specialized forensic training in treating sexual assault survivors and conducting medical forensic examinations. (6) SART The term sexual assault response team or SART means a multidisciplinary team that provides a specialized and immediate response to survivors of sexual assault, and may include health care personnel, law enforcement representatives, community-based survivor advocates, prosecutors, and forensic scientists. (7) Secretary The term Secretary means the Secretary of Health and Human Services. (8) Sexual assault The term sexual assault means any nonconsensual sexual act proscribed by Federal, tribal, or State law, including when the individual lacks capacity to consent. 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 shall award grants to States to develop and implement State surveys to identify— (1) the availability of and patient access to trained SAFE, SANE, and other providers who perform MFEs; (2) the hospitals or clinics that offer MFEs and whether each hospital or clinic has full-time, part-time, or on-call coverage; (3) regional, provider, or other barriers to access sexual assault care and services, including MFEs; (4) billing and reimbursement practices for MFEs, including private health insurance, Medicare, Medicaid, the State’s victims compensation program, and any other crime funding or other sources of funding that contribute to payment for such examinations; (5) State requirements, minimum standards, and protocols for training sexual assault examiners; (6) State requirements, minimum standards, and protocols for training non-SANE or SAFE emergency services personnel involved in MFEs; (7) the availability of SAFE or SANE training, frequency of when training is convened, the providers of such training, the State’s role in such training, and what process or procedures are in place for continuing education of such examiners; (8) the dedicated Federal and State funding to support SAFE or SANE training; and (9) funding opportunities for SANE or SAFE training and continuing education. (c) Eligibility To be eligible to receive a grant under this section, a State shall— (1) have public, private, or nonprofit 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 awarded under this section shall be published by the Secretary on the website of the Department of Health and Human Services on a biennial basis. (2) Campaigns A State that receives a grant under this section shall carry out the following: (A) Make the findings of the survey conducted under the grant public. (B) Use the findings to develop a strategic action plan to increase the number of trained examiners available in the State and create policies to increase survivor access to trained examiners. (C) Use the findings to develop and implement a public awareness campaign that includes the following: (i) An online toolkit describing how and where sexual assault survivors can obtain assistance and care, including MFEs, in the State. (ii) A Model Standard Response Protocol for health care providers to implement upon arrival of a patient seeking care for sexual assault. (iii) A Model Sexual Assault Response Team Protocol incorporating interdisciplinary community coordination between hospitals, emergency departments, hospital administration, local rape crisis programs, law enforcement, prosecuting attorneys, and other health and human service agencies and stakeholders with respect to delivering survivor-centered sexual assault care and MFEs. (iv) A notice of State and Federal laws prohibiting charging or billing survivors of sexual assault for care and services related to sexual assault. (e) Authorization of appropriations There is authorized to be appropriated to carry out this section, $2,000,000 for each of fiscal years 2019 through 2024. 102. Improving and strengthening the sexual assault examiner workforce clinical and continuing education pilot program (a) Purpose It is the purpose of this section to establish a pilot program to develop, test, and implement training and continuing education which expands and supports the availability of SAFE, SAE, and SANE, providers and services for survivors of sexual assault. (b) Establishment (1) In general Not later than 1 year after the date of enactment of this Act, the Secretary shall establish a National Continuing and Clinical Education Pilot Program for SAFEs, SANEs, and other individuals who perform such examinations in consultation with the Department of Justice, 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 of the Department of Justice, the Office on Violence Against Women of the Department of Justice, and the Office on Women’s Health of the Department of Health and Human Services and with input from regional and national organizations with expertise in forensic nursing, rape trauma or crisis counseling, investigating rape and gender violence cases, survivors’ advocacy and support, sexual assault prevention education, rural health, and responding to sexual violence in Native communities. Such pilot program shall be 2 years in duration. (2) Functions The pilot program established under paragraph (1) shall 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 or SANE practice of care, including— (A) training and continuing education to help support SAFEs or SANEs practicing in rural or underserved areas; (B) training to help connect sexual assault survivors who are Native American with SAFEs or SANEs, including through emergency first aid, referrals, culturally competent support, and forensic evidence collection in rural communities; (C) replication of successful SANE or SAFE programs to help develop and improve the evidence base for MFEs; and (D) training to increase the number of medical professionals who are considered SAFEs or SANEs based on the recommendations of the National Sexual Assault Forensic Examination Training Standards issued by the Department of Justice on Violence Against Women. (3) Eligibility to participate in pilot programs The Secretary shall ensure that SAFE or SANE services provided under the pilot program established under paragraph (1), and other medical forensic examiner services under the pilot program shall be provided by health care providers who are also one of the following: (A) A physician, including a resident physician. (B) A nurse practitioner. (C) A nurse midwife. (D) A physician assistant. (E) A certified nurse specialist. (F) A registered nurse. (G) A community health practitioner or a community health aide who has completed level III or level IV certification and training requirements. (4) Nature of training The continuing education program established under this section shall incorporate and reflect current best practices and standards on MFEs consistent with the purpose of this section. (c) Availability After termination of the pilot program established under subsection (b)(1), the training and continuing education program established under such program shall be available to all SAFEs, SANEs, and other providers employed by, or any individual providing services through, facilities that receive Federal funding. The Task Force established under section 201 shall review and recommend updates to the training and continuing education program after the termination of the pilot program. (d) Effective date (1) In general The pilot program established under this section shall terminate on the date that is 2 years after the date of such establishment. (2) Authority for modifications Upon termination of the pilot program as provided for in paragraph (1), the Secretary or the Task Force established under section 201 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. (e) Authorization There are authorized to be appropriated to carry out this section $5,000,000 for each of fiscal years 2019 through 2021. 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 of the Department of Justice, the Office on Women’s Health of the Department of Health and Human Services, 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 or SANE competencies, including— (1) providing comprehensive medical care to sexual assault patients; (2) demonstrating the ability to conduct a MFE 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 website of the Department of Health and Human Services an online public map of SAFE, SANE, and other forensic medical examiners. Such maps shall clarify if there is full-time, part-time, or on-call coverage. (2) States A State that receives Federal funds shall maintain and make available an online public map displaying the number and location of available SAFE or SANE programs and other forensic medical examiners in the State. Such maps shall clarify if there is full-time, part-time, or on-call coverage. 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 survivors who present at the hospital for MFEs in the year for which the report is being prepared; (2) the number of personnel who are trained and practicing as a SANE or SAFE to perform sexual assault exams, indicating the employment basis of such personnel as either full-time, part-time, or on-call; (3) the number of sexual assault exams performed by SANEs or SAFEs; (4) the number of sexual assault exams performed by personnel other than a SANE or SAFE; (5) the training that such SAFEs or SANEs undergo for purposes of maintaining competency; and (6) 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 identify barriers to improving access to SAFE/SANE and other forensic medical examiners. (b) Membership The Task Force shall include a representative from 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 of the Department of Justice, the Office on Women’s Health of the Department of Health and Human Services, and the Office on Violence Against Women of the Department of Justice, a survivor of sexual assault, and representatives from regional and national organizations with expertise in forensic nursing, rape trauma or crisis counseling, investigating rape and gender violence cases, survivors’ advocacy and support, sexual assault prevention education, rural health, and responding to sexual violence in Native communities. (c) Objectives To assist and standardize State-level efforts to improve medical forensic evidence collection relating to sexual assault, the Task Force shall— (1) identify barriers to the recruitment, training, and retention of SAFEs, SARTs, SANEs, and others who perform such examinations; (2) make recommendations for improving access to medical forensic examinations, including the feasibility of, or barriers to, utilizing mobile units; (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 Not later than 1 year after first convening, the Task Force shall report to the Secretary in a public document 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 MFEs and treatments relating to sexual assault. (2) Report Not later than 18 months 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 that includes the Task Force. 202. Institutions of higher education campus action plan Each institution of higher education that receives Federal funds shall— (1) inform survivors of sexual assault about the availability of MFEs, including the nearest available locations at which such examinations are provided by a SANE and that Federal law requires such exams to be provided at no cost to the survivor; and (2) make the information described in paragraph (1) available on the website of the institution, to the extent practicable. 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 survivors of sexual assault. (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 and to test the provisions of such services at new facilities in expanded health care settings. (c) Grants Under the program, the Secretary shall award 3-year grants to eligible entities that meet the requirements established by the Secretary. (d) Eligible entities To be eligible to receive a grant under this section, an entity shall— (1) be— (A) a rural health care services provider or community-based service 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— (i) assign rural health care service providers to the high-volume hospitals for clinical practicum hours to qualify such providers as a SAFE/SANE; or (ii) 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; or (B) an organization described in section 501(c)(3) of the Internal Revenue Code of 1986 and exempt from taxation under 501(a) of that Act, that provides legal training and technical assistance to tribal communities and to organizations and agencies serving Native people; and (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 one fiscal year to the next without obtaining approval from the Secretary. (f) Authorization of appropriations (1) In general There is authorized to be appropriated to carry out this section $11,000,000 for each of fiscal years 2019 through 2024. (2) Set-aside Of the amount appropriated under this subsection for a fiscal year, the Secretary shall reserve 15 percent of such amount for purposes of making grants to entities that are affiliated with Indian tribes or tribal organizations (as defined in section 4 of the Indian Self-Determination and Education Assistance Act ( 25 U.S.C. 5304 )), or Urban Indian organizations (as defined in section 4 of the Indian Health Care Improvement Act ( 25 U.S.C. 1603 )). Amounts reserved may be used to support referrals and the delivery of emergency first aid, culturally competent support, and forensic evidence collection training. . 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, MFEs 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, MFEs. (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(a)(2) ). 206. Oversight Not later than one 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 ( 34 U.S.C. 12291 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 survivors.