(a) The SAFE Program shall develop and implement written policies and procedures establishing an internal quality improvement program to identify, evaluate, resolve and monitor actual and potential problems in patient care. The internal program shall be integrated with the hospital's overall quality improvement plan and shall include, but not be limited to, the following components:

1. (1) chart audits performed periodically on a statistically significant number of sexual assault patient records. The hospital must designate one or more individuals to review sexual assault patient records periodically, along with other appropriate information, to determine the following:

   1. (i) length of time the patient waited from arrival to exam commencement;
   2. (ii) availability of appropriately trained staff to examine the patient;
   3. (iii) availability of all of the necessary equipment for the examination;
   4. (iv) if a rape crisis program advocate was contacted to accompany the patient;
   5. (v) if consent was appropriately obtained from the patient or the person authorized to give consent on behalf of the patient;
   6. (vi) if the patient received appropriate medical treatment;
   7. (vii) if HIV prophylaxis was recommended in all cases, when appropriate, pursuant to this DOH protocol (for the most recent version of the HIV guidelines, visit www.hivguidelines.org);
   8. (viii) If HIV prophylaxis was made available on-site to all clients requesting this preventive measure;
   9. (ix) for female patients, whether the patient received appropriate counseling relating to pregnancy prophylaxis and whether the patient received on-site pregnancy prophylaxis if the patient requested it;
   10. (x) if the patient received treatment for STDs, including prophylaxis;
   11. (xi) if forensic evidence was collected in a manner consistent with law, regulations and standards, including maintenance of the chain of custody;
   12. (xii) if an appropriate medical and psychosocial referral and follow-up plan were developed for the patient;
   13. (xiii) if safe discharge was assured for the patient; and
   14. (ix) if confidentiality was maintained;
2. (2) a system for developing and recommending corrective actions to resolve identified problems; and
3. (3) a follow-up process to assure that recommendations and plans of correction are implemented.