(a) The hospital shall ensure that the following minimum requirements are met throughout the period of its designation as a SAFE Program:

1. (1) appropriate administrative and clinical oversight is provided to the program;
2. (2) SAFE Programs are affiliated with and integrated into the policies and procedures and operations of related areas of the hospital, particularly emergency services;
3. (3) initial and ongoing assessment of competency and credentialing of SAFE staff is conducted, including certification of sexual assault forensic examiners by the department;
4. (4) effective systems to provide triage and assessment are incorporated;

5. (5) effective on-call and back-up call schedules have been developed to ensure that the patient is met by a sexual assault forensic examiner within 60 minutes of patient's arrival in the hospital except:

   1. (i) when the patient does not disclose a sexual assault at the time of triage; or
   2. (ii) under exigent circumstances;
6. (6) the rape crisis center is contacted immediately to ensure that a rape crisis advocate is available to offer services to the patient;
7. (7) medical/surgical backup is readily available to the sexual assault forensic examiner;
8. (8) an appropriately equipped, private, designated room with access to a shower that can accommodate patients with disabilities is available when needed for sexual assault exams;
9. (9) medical treatment and forensic examinations of sexual assault survivors are provided in compliance with all relevant laws and regulations and consistent with generally accepted standards of care, including standards such as those incorporated in the Department's Protocol for the Acute Care of the Adult Patient Reporting Sexual Assault (as currently posted on the DOH website at www.health.state.ny.us/nysdoh/sexual_assault/index.htm);
10. (10) prophylaxis for sexually transmitted diseases, HIV and hepatitis B, and prophylaxis against pregnancy resulting from a sexual assault (emergency contraception) are provided on site;
11. (11) the New York State Sexual Offense Evidence Collection Kit is used, unless a patient or person authorized to consent on the patient's behalf refuses to have evidence collected; and evidence is maintained and collected as required by Public Health Law, section 2805-i;
12. (12) replacement clothing is provided to the patient, if necessary, before the patient leaves the hospital;
13. (13) referral and follow-up regarding medical treatment is provided;
14. (14) the patient is referred to counseling and support and other needed services;
15. (15) safe discharge is reasonably assured for the patient;
16. (16) medical and forensic SAFE services are appropriately documented;
17. (17) information is collected related to the provision of services to survivors of sexual assault and confidentiality of the data is ensured; and
18. (18) an effective system of continuous quality improvement is established to ensure SAFE medical and forensic services are in compliance with generally accepted standards of care.