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EVAWI > Resources > Forensic Compliance > FAQs > Forensic Exam
Forensic Compliance Frequently Asked Questions

Note: The information on this website is designed to: (a) communicate the requirements of the Violence Against Women Act (as reauthorized in 2005 and 2013), and (b) offer recommended practices for implementation. The goal is to highlight examples of communities striving to achieve a higher standard of the “spirit of the law,” rather than simply meeting the “letter of the law” for VAWA forensic compliance.  It is critically important that readers consult state laws and regulations, as well as local policies and protocols, because they may have additional requirements beyond those included in VAWA 2005 and VAWA 2013. For more information specific to your state or territory, contact the STOP Grant Administrator or coalition of advocacy organizations providing services for sexual assault victims.  A listing is available from the website for the Office on Violence Against Women, U.S. Department of Justice.

Q Our hospital is considering the possibility of contracting with SANE nurses to provide medical forensic exams. What factors need to be considered?
A Our hospital is considering the possibility of contracting with SANE nurses to provide medical forensic exams. What factors need to be considered?

Contracting of nursing services is common in the health care field. From using agency nurses or “traveling” nurse contractors, most hospitals are familiar with utilizing contract nurses in many areas of the hospital. Nurses may be contracted on an individual basis, or they may work for an organization that contracts with the hospital or law enforcement agency to provide forensic medical services. They may be used to fill in temporary staffing gaps before more permanent staff can be hired, or to fill in for staff nurses on leave or during vacation periods. A SANE program may also consider using contract services for their medical forensic exams -- either to augment existing staff by filling in temporary gaps, or as a permanent solution to address staffing needs.

To provide a hypothetical example:

Nurse Hernandez RN might serve as an independent contractor who is contracted by an organization called Forensic Nursing Services (FNS) to provide medical forensic examination services to local hospitals. She contracts with this organization and must supply her own license and liability insurance. She receives no benefits beyond direct compensation from FNS, in accordance with her contract. FNS then puts her on a schedule to work or take call based on Nurse Hernandez’ availability.

Creating Contractual Arrangements

When considering such an arrangement there are a several different options to research. First, it is important to determine if the facility is currently using any agency or contract services. It may save a great deal of time and effort to begin by meeting with human resources or staffing offices within the hospital -- to discuss the mechanisms that are already in place for contract nursing services. It may be that these arrangements can be easily adapted for use with contract SANE services.

If there are no existing mechanisms in place for the use of temporary nursing services, more extensive work may be needed to establish a process for hiring non-employee staff. This may include the hospital setting up a process for obtaining practice or hospital privileges that would allow contract SANEs to respond and complete medical forensic exams in hospitals where they are not employed as hospital staff. Unfortunately, the process of obtaining these practice privileges can require an application process that is both expensive, time consuming and administratively complicated.

Requirements for Contract SANEs

Beyond practice privileges, there are a number of requirements for contract SANEs that must be considered when developing a contract. For example, contract SANEs should be required to carry independent professional liability insurance. Contractual staff are also typically required to participate in some form of hospital orientation to ensure they are familiar with hospital policies and safety procedures, and also that they have the minimum required knowledge to practice in the facility in general and in the SANE program. Other considerations include additional expenses such as reimbursement for professional liability costs and annual Continuing Education, as well as SANE-A and/or SANE-P certification costs, if these are required by the hospital or community protocol.

Written Contractual Agreement

Regardless of whether a SANE program is community-based or hospital-based, any arrangement with a non-employee SANE will require developing a written contractual agreement regarding the services provided. The contract will need to include provisions regarding any on-call time and actual examination time, as well as preparation for court and testimony. Any nursing contract should also provide information about the level and extent of care that will be provided to patients, as well as a detailed outline of the responsibilities for both the employing agency and the contract SANE.

Detailed information will also be required for the reimbursement of SANE services performed. This includes outlining the reimbursement for "on-call" time, examination time and court testimony time. If the SANE contractor is being hired as an independent contractor, the contract should also clarify whether the agency will be responsible for deducting payroll taxes and payment terms. Clearly, the cost of contract staff may add up quickly, depending upon the number of contract staff needed. Detailed information should also be provided on the process and turnaround time for payment.

Court Testimony Obligations

It is imperative for any contract SANE to clearly understand the expectations associated with subpoenas, pre-trial preparation, and court testimony. It should be clear that any cases they are responsible for will have associated commitments in these areas for the contracting SANE. Additionally, the contract should specify how SANEs will be compensated for this time and what costs will be covered once the SANE is no longer on contract. SANEs typically have full-time jobs, and they may need to take leave from their primary employment in order to testify in court.

Contract SANEs who are not on staff at a hospital may also be subject to very different facility policies and restrictions (over and above HIPAA) regarding their access to patient records, reports, and photographs. Such restrictions may impede the SANE’s ability to prepare for court and in many cases will require additional time to navigate administrative channels. Typically, contract nurses will need to ask the attorney who called them to testify for access to the report and pictures for trial preparation.

Issues to Address

Scheduling contract SANEs can pose additional challenges for a SANE program manager. There may be a need to modify usual response times and also to address issues such as required response times, inclement weather and other potential delays. It is important to identify these situations in advance and clarify any expectations in the contractual agreement. It is also recommended that the SANE program manager communicate with law enforcement or any other paying agency about any contract SANE services being utilized and how that might impact any contract between the medical facility and law enforcement.

To summarize, any hospital contract for contract SANE services should include clear provisions addressing:

  • On-call pay
  • The number of shifts required during a pay period
  • Required response times for the SANE upon notification of a case
  • Practice privileges (including any fees, if applicable)
  • Exam payments and billing information
  • Court preparation and testimony agreements
  • Training and orientation requirements including any reimbursement
  • Certification requirements
  • Clinical competency with supervision
  • Annual continuing education requirements and reimbursement
  • Professional liability insurance
  • Awareness of and compliance with the existing community/facility exam protocol
  • Peer review

The contract should also include an acknowledgement of subpoena compliance mandates and applicable legal penalties, even in situation where the SANE no longer contracts with the hospital or the agency conducting medical forensic exams.

Administrative Coordination

Any type of contractual arrangement will typically require strong administrative coordination -- to manage payment to the forensic examiner as well as billing the agency ultimately responsible for covering exam costs, scheduling, subpoenas, and the other issues mentioned above.

There is an added complication when contract SANEs were former hospital employees. In this situation, the contractor will no longer enjoy the benefit of the hospital providing administrative and policy protections and other managerial assistance. This can be a difficult transition to working as a contract SANE. This is particularly true when it comes to issues of administrative logistics, accounting systems, insurance provisions, tax issues and risk management. There should be clear communication regarding what the hospital will and will not provide to the contractor.

Templates Available

To provide guidance in this area, we have several examples of contract templates. These examples were collected by Diana Faugno with the Eisenhower Medical Center (which is headquartered in Rancho Mirage, California) and Kim Day, who serves as the SAFEta Project Director at the International Association of Forensic Nurses (IAFN). We are grateful for their efforts to provide these contract templates as training resources.

The contract templates are provided in Word format, so they can be easily adapted for your own use. They are drawn from a broad range of programs, so they offer a sense of the diversity that can be seen in free-standing facilities, as well as community-based and hospital-based forensic examiner programs. We hope you find them helpful.

For More Information

Additional resources include the following:

Acknowledgements

We would like to gratefully acknowledge the efforts of several people who contributed significantly to this response:

  • Ann Burdges, CEO / Executive Director of the Gwinnett Sexual Assault Center & Children’s Advocacy Center (GSAC-CAC) and Deputy Director for EVAWI.
  • Kim Day, RN, FNE, SANE-A, SANE-P, SAFEta Coordinator for the International Association of Forensic Nurses (IAFN). Please contact Kim Day at kimday@iafn.org for information and technical assistance on the medical forensic exam and the National SAFE Protocol.
  • Diana Faugno, MSN, RN, CPN, SANE-A, SANE-P, FAAFS, DF-IAFN, Eisenhower Medical Center
This project is supported by Grant No. 2013-TA-AX-K045 awarded by the Office on Violence Against Women, U.S. Department of Justice. The opinions, findings, conclusions, and recommendations expressed on this website are those of the author(s) and do not necessarily reflect the views of the Department of Justice, Office on Violence Against Women.
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