Sac State University Policy Manual
Campus Health Services Oversight Policy
Policy Administrator: Vice President for Student Affairs
Authority: PM 03-10, Executive Order 814
Effective Date: October 3, 2008
Index Cross-References:
Policy File Number: STU-0108




  • Overview/Purpose


The President or designee shall ensure appropriate oversight of all University health services. The purpose of this policy is to outline standards and guidelines for the provision of health services to students, employees, and visitors by all campus entities, e.g., student health centers (SHC), athletic departments, academic programs and auxiliary organizations. The intent is to assure compliance with relevant California State University policy, privacy practices, and federal, state and local laws.


  • Scope


This policy applies to all California State University, Sacramento (hereafter referred to as Sacramento State) departments/programs and auxiliaries that provide health services.
Nothing in this policy shall supersede California State University Trustees' Policy or applicable Executive Orders. This policy would not apply to first aid administered on campus, except by departments or programs that otherwise are considered being health service entities.


  • Definition of Campus Health Services


Health services shall be defined as the assessment and treatment or referral for treatment of medical conditions provided by a department or program of Sacramento State or one of its auxiliaries. Immunization administration and health promotion are considered health services.

Departments and/or programs which currently provide health services are:

      • The Student Health Center (SHC) and the Connection
      • Athletic Medicine
      • Psychological Counseling Services (PCS)
      • Employee Assistance Program
      • Health services rendered as part of an academic program under the supervision of an appropriately qualified faculty member, e.g.:
        • Nursing
        • Physical Therapy
        • Athletic Training
        • Kinesiology
        • Speech Pathology and Audiology
        • Department of Counselor Education
        • Services for Students with Disabilities
        • Any other academic program that renders definitive health services, refers to community health services, and/or documents health services.
  • Standards/Guidelines


      • Each provider's role and responsibility are determined by their professional skills, competence, and credentials.
      • Credentialing is the process by which determination of provider qualification will be guided by state law, CSU Classification and Qualification Standards, National Practitioner Data Bank review, professional references and accreditation agency guidelines.
      • The President or his designee is responsible for credentialing providers of health care. The Office of Human Resources will provide initial review of all applications to ensure CSU Professional Classifications and Qualification Standards are met. The SHC Credentials Committee shall review and act on all SHC and Athletic Medicine credential applications. Credentialing for all licensed SHC and Athletic Medicine providers will be reviewed annually by the SHC Credentialing Committee. Each licensed health care provider must:
        • Meet the standards of practice for the service area.
        • Practice within the scope of his/her licensure, certification, and training.
        • Meet the requirements/minimum qualifications set forth by the California State University Board of Trustees.
        • Possess and maintain a valid and relevant California professional license.
        • Consent to a confidential review of his/her licensure by the Credentialing Committee which may include the confidential contact of external agencies to confirm professional experience, history and expertise.
      • Unlicensed individuals providing health care (e.g., athletic trainers) must do so under the supervision of a physician or other appropriately licensed provider.
      • Where there are applicable standards, each area will establish or implement and comply according to the professional group or accreditation body specific to their area.
      • Where appropriate, the provider of a service shall be licensed, certified, and trained within the applicable guidelines for the licensure or certification.
      • Written policies and procedures shall be maintained that define the scope of services and basic guidelines of practice.
  • Environmental Health, Safety, and Risk Management


      • All campus activities providing any form of health services to any Sacramento State student or employee will ensure a clean, safe, functional and effective environment to reduce the risk of negative environmental outcomes, injuries and the spread of disease.


      • Health providers or facilities that stock or provide medications to patients shall establish special security measures to secure and document the dispensing of such pharmaceuticals and over the counter drugs. A professional (licensed) pharmacist shall evaluate the processes, procedures, and safeguards to insure compliance with applicable federal and state laws and regulations.


      • Medical equipment and/or devices used shall comply with appropriate safety standards and shall be inspected and calibrated as required by state, local, or federal law and comply with accreditation requirements.


      • The Office of Environmental Health and Safety (EHS) shall establish procedures for the disposal of biohazard waste materials generated in the course of the provision of health services. Used needles, syringes, and the like shall be stored onsite in appropriate puncture and tamper proof containers.  Paper and other medical waste shall be placed in appropriately identifiable bags/containers. Disposal of all health services waste shall be consistent with state, local and federal laws. The responsibility for determining the need and specifications for a biohazard waste disposal contract with a commercial vendor shall rest with the director of EHS.


      • Campus entities should consult with the Offices of Risk Management and General Counsel to ensure adequate coverage for insurance and liability coverage.


  • Protected Health Information


      • The Medical Record


        • Information shall be considered confidential and secured in compliance with state and federal laws (Family Education, Records Privacy Act, Health Insurance Portability & Accountability Act (HIPPA), California Information Practices Act {Civil Code §1798.1 et seq., and Confidentiality of Medical Information Act {Civil Code § 56 et seq.} ), and other mandated laws or policies.


        • Contains documentation in a given area and shall meet the guidelines of the applicable profession as defined by an appropriate oversight organization or accreditation organization for that area.  At minimum, the documentation shall include:


          • Name of the recipient (patient)
          • Date
          • Location
          • The health service provided
          • Name and professional discipline (i.e. MD, RN, FNP, etc.) of the provider(s)


      • Protection and Release of Medical Information


        • Medical information is not part of the academic record except as specified in the Family Education Records Privacy Act (FERPA) and other laws that may apply.


        • For non-students, the provisions of HIPPA apply if the program is declared a health care component of the University; if not designated as being subject to HIPPA and/or if California law is more stringent, then California privacy laws shall apply.


        • Disclosures relating to patients may generally only be made with the specific consent of the patient except for the purposes exempted by law or court order.


        • If subject to HIPPA, a notice of privacy practices must be provided to each patient at the time of first visit or treatment and acknowledged in writing by the patient.


        • No medical information shall be made available for marketing purposes.


        • Medical information that identifies a specific individual shall not be released. Medical information that is statistical in nature and does not identify an individual may be released subject to appropriate approval of the campus Institutional Review Board (IRB).


        • Contractors, vendors, and other third parties, which may have access to medical information in the course of supporting a health service, shall demonstrate compliance with applicable security and privacy standards.


        • Releases under subpoena or at the request of government agencies or law enforcement agencies shall be processed through the University Counsel.


        • Medical information (i.e. medical records) shall be secured. Access to such records shall be limited to the minimum necessary to accomplish the records maintenance function.


  • Oversight


      • When a campus entity engages in the provision of health services, the President or designee shall identify one individual as responsible for the oversight of the program.


        • The Director of the Student Health Center is responsible for the delivery of health care services at the SHC and the Connection.


        • The Athletic Director is responsible for the athletic medicine program and shall designate in writing a physician to exercise medical oversight for the delivery of health services. Policies and procedures for the athletic medicine program shall be in writing and approved by the designated physician.


        • The Dean or designee is responsible for the delivery of health care services as part of an academic program.


      • Control and dispensing of prescription drugs shall be subject to review by a professional (licensed) pharmacist. The athletic medicine program shall make appropriate arrangements to consult with a professional pharmacist when medications are stored and/or dispensed by the program; the program shall also make arrangements for periodic review of such medication storage and dispensing policies and procedures by a professional pharmacist.


      • All service areas shall engage in an ongoing, documented process of review and improvement of its offering. This process shall include but is not limited to:


        • Peer Review


        • A system for documenting and evaluation unusual occurrences. Any adverse outcome of a health service provided shall be reported as soon as possible to the campus Risk Manager. An outcome should be considered adverse if:


          • The patient or client reports physical, personal, or financial loss as a result of an action or inaction.


          • The patient or client reports harm physically, psychologically, or financially by an assessment, treatment, or referral.


          • The patient or client must seek treatment elsewhere due to an unplanned outcome of a service provided.


          • The patient or client may file a claim against the University.
        • A regular review of its operation and its compliance with standards of operation and relevant campus, California State University, governmental, and ethical guidelines.
        • An assessment of the timeliness and appropriateness of its services.
  • Student Health Advisory Committee


The President or designee shall establish a student health advisory committee.

      • The Committee shall be advisory to the President or designee and the Student Health Center.
      • The Committee shall advise on:
        • Scope of service
        • Delivery of health services and psychological counseling services
        • Funding
        • Other critical issues relating to campus health services
      • Membership. Students shall constitute a majority of committee membership. The committee shall be comprised of the following:
        • One faculty member appointed by the Faculty Senate
        • A student appointee from the residence halls
        • A student director from Associated Students
        • A student appointee from Services to Students with Disabilities
        • Two representatives of the Health Center staff appointed by the Director of the Health Center
        • One representative from Psychological Counseling Services appointed by the PCS Director
  • Coordination of Health Services Between the Student Health Center and the Department of Intercollegiate Athletics


      • Student athletes are regular students of the University and are therefore eligible for health services from the SHC. The Department of Intercollegiate Athletics may fund and/or provide additional health services to student athletes, including but not limited to services from team physicians, trainers, and the training room.
      • Intercollegiate Athletics and the SHC share a mutual interest in the health of student athletes. As such, the following coordinating procedures apply:
        • Intercollegiate Athletics shall, when referring a student athlete for supported services, ensure that an appropriate consent to disclose medical information is initiated, signed and dated by the student athlete and will specifically permit exchange of medical information between team physicians, trainers, SHC physicians and other SHC clinical staff members as necessary for the effective care of the student athlete. Copies of consent forms shall be provided to the SHC on an as-needed basis.
        • Coaches, administrators and others who are not directly engaged in the treatment process have no “right of access” to private health care information without a patient’s written consent. Release of medical information in response to a request from the Western Athletic Conference, National Collegiate Athletic Association or other sports authority shall be processed in accordance with all state and federal laws including FERPA, HIPAA, the California Information Practice Act and the Confidentiality of Medical Information Act.
        • Care rendered to student athletes by team physicians shall be documented and maintained by such means as is determined by Intercollegiate Athletics. However, any system of records shall meet or exceed standards established for the SHC.
      • Reimbursement for Health Services
        • When so agreed, Intercollegiate Athletics shall pay SHC charges for services which would otherwise be the responsibility of the student athlete. Student athletes eligible for paid services will be provided a “Treatment Authorization” form which will identify the student athlete, the services to be paid, and will be signed and dated by an authorized representative from Intercollegiate Athletics. The student athlete must present the form to the SHC at the time the services are rendered. Intercollegiate Athletics shall be the sole authority to determine which services shall be paid for by Intercollegiate Athletics; the student athlete shall be responsible for payment of any charges not paid for by Intercollegiate Athletics.
        • Student costs for specified services in the SHC will be invoiced monthly to Intercollegiate Athletics with an itemized listing of services rendered and the cost for each service attached, e.g. laboratory tests, x-rays, and pharmaceuticals. All charges will be at SHC rates and charges in effect at the time the service is rendered.
      • Intercollegiate Athletics will provide to the SHC on an annual basis a written listing by name and telephone number of team physicians, professional trainers, student trainers, and any other medical provider.
      • SHC will honor prescriptions from team physicians and will provide copies of x-rays and clinical laboratory test results to the team physician or his/her designee upon request. Test results will not be provided to student trainers unless authorized in writing to do so by the physician responsible for medical oversight of the athletic medicine program.
      • Coordination of care will be routinely accomplished between SHC clinical staff members and team physicians (or professional trainers when so designated). The senior trainer or the trainer for each sport, as designated by Intercollegiate Athletics, shall act as liaison between the SHC and the team physician(s). Transportation of an injured or ill student athlete to the SHC shall be the responsibility of Intercollegiate Athletics, and normally shall be preceded by a notification call in order to ensure that adequate staff and facilities are available. SHC shall notify Intercollegiate Athletics in a timely fashion should certain services not be available and the expected duration of the non-availability.
      • In order to ensure effective coordination of services, SHC staff members shall meet with Intercollegiate Athletics team physicians and/or trainers on at least an annual basis or as necessary by mutual agreement.
  • Medical Disaster Planning


      • The President (or designated representative) shall be responsible for ensuring that campus emergency plans include a provision for the training and assignment of SHC staff in disasters that may require emergency medical services.
      • The SHC staff shall annually review and update the medical disaster procedures of the campus emergency plan.
      • The Director of the SHC may make recommendations to the President (or designated representative) the delivery of health services during emergency operations.
  • Required Reporting


      • An annual report describing the status of all health services operations provided to the campus including a written listing of all health services provided.
      • CSU benchmarking and customer satisfaction surveys.
      • Any and all reports to accreditation bodies if performed during the year.
      • Copies of revisions to the campus oversight policies must be submitted to the President for approval.

  • Approval


This policy shall be reviewed and approved by the President.


Approved by Alexander Gonzalez, President

October 3, 2008