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July 13, 2018 the Honorable Greg Walden, Chairman the Honorable July 13, 2018 The Honorable Greg Walden, Chairman The Honorable Frank Pallone, Jr., Ranking Member The Honorable Gregg Harper, Chairman, Subcommittee on Oversight and Investigations The Honorable Diana DeGette, Ranking Member, Subcommittee on Oversight and Investigations Committee on Energy and Commerce U.S. House of Representatives 2125 Rayburn House Office Building Washington, D.C. 20515-6115 Re: Letter to Texas Hospital Association Regarding the Availability of Sexual Assault Forensic Exams in Texas Hospitals Dear Chairman Walden, Chairman Harper, Congressman Pallone, and Congresswoman DeGette: This letter and the enclosures are sent in response to the U.S. House of Representatives Committee on Energy and Commerce’s letter of June 21, 2018 to the Texas Hospital Association1. We appreciate and thank you for your inquiry into the process in Texas related to access to sexual assault forensic examiners and forensic medical exams for sexual assault survivors. The Texas Hospital Association is a statewide leadership organization and principal advocate for the state's hospitals and health care systems. Based in Austin, THA enhances its members' abilities to improve accessibility, quality and cost-effectiveness of health care for all Texans. THA represents 465 hospitals throughout Texas. THA has a long history of working with victims’ rights organizations, law enforcement, state regulatory agencies and the Texas Legislature in support of increasing access to sexual assault forensic examiners and forensic medical exams. Stakeholders in Texas, along with THA, have been working since 2005 to develop a process that balances the availability of sexual assault forensic examiners with the geographic size and population of the state. According to the Texas Department of State Health Services (DSHS), there are 648 state-licensed hospitals in Texas. There are 219 state-licensed freestanding emergency care facilities (FEC). This is a total of 867 facilities with an emergency department. According to the Texas Attorney General, there are 360 certified Sexual Assault Nurse Examiners statewide2. 1 THA’s complete response is comprised of this letter and the accompanying attachments, totaling 25 pages, 001- 025. 2 This information was received in response to a direct inquiry to the Texas Attorney General’s Office by THA. To our knowledge, there is no publicly available database or link to this information. 001 U. S. House of Representatives Energy and Commerce Committee July 13, 2018 Page 2 of 6 The process in Texas related to the provision of services for survivors of sexual assault is found in the Texas Health and Safety Code, Chapter 323. The state law is applicable to hospitals with an emergency department and to FECs. A summary of the Texas law can be found in the answer to question number five, below. ANSWERS TO SPECIFIC COMMITTEE QUESTIONS. THA provides the following information as requested by the Committee: Question No. 1: How many hospitals in Texas is the Texas Hospital Association aware of that have a SANE program: Response: The Texas Hospital Association does not maintain this information independently. However, according to the DSHS, 110 facilities in Texas are designated as a SAFE-Ready facility. A SAFE-Ready facility is a facility that employs or contracts with a sexual assault forensic examiner or uses a telemedicine system of sexual assault forensic examiners to provide consultation to a licensed nurse or physician when conducting a forensic medical exam. A copy of the Department’s listing of SAFE-Ready facilities is enclosed under Tab 1, 007-009. Question No. 2: Does the Texas Hospital Association maintain a database of hospitals and/or other entities across Texas that have a SANE program? a. If so, is that database available publicly? Response: The Texas Hospital Association does not maintain a database of hospitals and/or other entities across Texas that have a SANE program. However, a database of SAFE-Ready facilities is statutorily required and is maintained by the DSHS. That database is available publicly and can be found at: http://www.dshs.texas.gov/facilities/sexual-assault-information.aspx. A printout of the most current public listing is enclosed under Tab 1, 007-009. Question No. 3: What steps, if any, has the Texas Hospital Association taken to increase access or address the lack of access to SAFE kits in hospitals across Texas. a. Does THA partner with law enforcement agencies in any capacity to provide access to SAFE kits? Response: THA has a long history of working with victims’ rights organizations, law enforcement, state agencies and the Texas Legislature in support of increasing access to sexual assault forensic examiners and forensic medical exams. THA has actively supported legislation increasing access for sexual assault survivors in emergency departments and has taken an active role in educating hospital members about new and changing statutory requirements. However, in response to the Committee’s specific inquiry, other than its general advocacy efforts, THA has not undertaken any steps specifically to increase or address the lack of access to SAFE kits, nor has it partnered with law enforcement agencies to provide access to SAFE kits. 002 U. S. House of Representatives Energy and Commerce Committee July 13, 2018 Page 3 of 6 Question No. 4. What challenges has the Texas Hospital Association identified that hospitals face in providing access to these services? a. How is THA working with your hospitals to address those challenges? Response: Texas hospitals’ primary challenge to providing access to sexual assault services lies in the size, geography and population of the state. The cost and intensive requirements of a SANE program can also be a challenge. There are 867 facilities with an emergency department across the state. There are 360 certified sexual assault forensic examiners. The lack of certified examiners renders it impossible to locate a certified SANE at every Texas emergency department. The intensive nature and upkeep of the SANE certification and the relative infrequency of performing sexual assault forensic exams in remote or rural emergency departments also add to the challenges of ensuring all facilities are SAFE-Ready. A SANE program is the preferred path for sexual assault forensic exams and evidence collection. THA, through its legislative advocacy and its member education, has worked to ensure that there is an available sexual assault forensic process at all emergency departments in Texas while maintaining an emphasis on the importance of having SAFE- Ready facilities available in communities statewide for sexual assault survivors. Question No. 5: For hospitals in Texas that do not have a SANE program does the Texas Hospital Association provide guidance, standards or best practices on how to treat patients that come to the hospital seeking a SAFE kit? Response: THA does not provide any guidance, standard or best practices on how to treat patients. THA endeavors to educate its member hospitals on changes in the law by providing summaries of statutory changes to its member hospitals, including summaries of changes to Texas Health and Safety Code chapter 323 related to the provision of emergency services for survivors of sexual assault. Please see the enclosure under Tab 2, 010-012, an excerpt from THA’s Health Law Manual containing a summary of HB 3152, legislation passed by the Texas Legislature in 2017 related to SAFE-Ready facilities and access to forensic medical exams. The Health Law Manual is provided to all member hospitals. Question No. 5a: If so, what procedures are recommended? Response: N/A Question No. 5b: If so, please provide copies of any such guidance. Response: Please see the enclosure under Tab 2, 010-012, an excerpt from THA’s Health Law Manual containing a summary of HB 3152, legislation passed by the Texas Legislature in 2017 related to SAFE-Ready facilities and access to forensic medical exams. The Health Law Manual is provided to all member hospitals. 003 U. S. House of Representatives Energy and Commerce Committee July 13, 2018 Page 4 of 6 Question No. 5c: Do procedures vary for hospitals in rural and urban areas, or based on the availability of local alternatives, such as a rape crisis center? Response: Yes, the statutory requirements vary for emergency department facilities that are designated as SAFE-Ready versus those that are not designated. Summary of Texas process for emergency services for survivors of sexual assault: The process in Texas related to the provision of services for survivors of sexual assault is found in the Texas Health and Safety Code, Chapter 323. The state law is applicable to hospitals with an emergency department and licensed FECs. According to Texas law, every hospital with an emergency department and every FEC must be able to provide a forensic medical exam onsite. The person who performs the exam must have at least basic forensic evidence collection training as approved by the appropriate state licensing board. The facility must have a plan to train personnel on forensic evidence collection. Additionally, upon request of the DSHS, each facility must submit for approval a plan for providing the statutorily-required services. The required services in the plan include: a private area (if available) to wait and speak with appropriate medical, legal or crisis center staff; access to a sexual assault program advocate (if available); the required DSHS information forms including details on the forensic evidence collection process (see
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