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 University Policy Manual
 California State University, Sacramento
Policy Title: Campus Health Oversight Policy

Policy Administrator: Vice President for Student Affairs
Authority: PM 03-10, Executive Order 943
Effective Date: January 12, 2015
Updated: January 7, 2015; October 3, 2008
Index Cross References:
Policy File Number:


Policy Statement:
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 & Counseling Services (SHCS), athletic departments, academic programs and auxiliary organizations. The intent is to assure compliance with relevant California State University policies, privacy practices, and federal and state laws.

Who the Policy applies to:
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.

Health services are defined as the assessment, treatment, or referral for treatment of medical and health-related conditions including immunizations and health education programs provided by a department or program of Sacramento State or one of its auxiliaries. Departments and/or programs which currently provide health services at Sacramento State:

  • Student Health & Counseling Services (SHCS) at The WELL
  • Athletic Medicine
  • Occupational Health
  • Student Services With Disabilities (SSWD)
  • Risk Management/Workers Compensation
  • Nursing
  • Physical Therapy
  • Athletic Training
  • Kinesiology
  • Speech Pathology and Audiology
  • Department of Counselor Education

Any other program that wishes to begin providing health services as determined by the definition above must identify these services to the President and/or designee and to the Campus Health Oversight Committee.

Why the Policy is necessary:
Executive Order 943, Policy on University Health Services, requires the President or a designee to ensure appropriate oversight of all University health services. 

This policy is administered by the Vice President for Student Affairs.  The responsibilities for ensuring quality of care and compliance with all applicable regulations, however, rests with the administrators who directly oversee each provider (e.g. the Dean of the College of Health and Human Services for the Department of Speech and Audiology).  Thus, to ensure proper standards of care, only those providers on-campus who have been “qualified” to provide health care will be allowed to do so.  Qualification will be determined by the process of credentialing.  Standards for qualification will be set for each professional category guided by state law, CSU Professional Classifications and Qualification Standards, National Practitioner Data Bank review, professional references, and accreditation agency guidelines. 

  • The Office of Human Resources will provide initial review of all applications to ensure CSU Professional Classifications and Qualification Standards are met.
  • At Sacramento State, the designee to further credential providers of health care is the Executive Director of SHCS or the Department Director/Chair for which the person is assigned.
  • 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 by the provider which defines the scope of services and basic guidelines of practice.

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. 

At Sacramento State, the persons or entities responsible for the oversight of the health services are identified as follows:

  • The Executive Director of the Student Health & Counseling Services is responsible for the delivery of health care services at the SHCS.
  • The Athletic Director is responsible for the athletic medicine program and shall designate in writing a physician(s) 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 team physician(s).
  • Each college dean or designee is responsible for the delivery of health care services as part of an academic program housed within their college.

In addition to oversight of health services delivery, control and dispensing of prescription drugs shall be subject to review by a professional (licensed) pharmacist. Departments dispensing prescription drugs 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 campus activities providing health services will ensure a safe environment to reduce the risk of illness or injury.  Definition of a “safe” environment may include guidelines and requirements from:

  • Cal-OSHA
  • Standards of practice for specific health services provided
  • Accreditation organizations
  • Relevant State, County, Local entities
  • Sacramento State Environmental Health and Safety/Risk Management Department
  • Sacramento State Campus Police Department
  • Sacramento State Facilities Department

Specific policies that ensure compliance with state and federal laws shall apply to the security of:

  • Pharmaceuticals – A licensed pharmacist shall evaluate the processes, procedures, and safeguards to ensure compliance with applicable federal and state laws and regulations for any facilities that contain prescription drugs.
  • Medical Records and facilities that contain protected health information
  • Biohazard waste disposal
  • 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.

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

In addition to direct oversight of health services, the President or designee shall establish a Student Health Advisory Committee (SHAC).  SHAC is a student-based organization that advises the Vice President of Student Affairs and the Executive Director of SHCS on issues of on-campus health service delivery from students’ perspectives related to:

  • Accessibility
  • Hours of operation
  • Scope of Services
  • Student fees
  • Quality of care
  • Patient satisfaction

Students shall constitute a majority of committee membership. The committee shall be comprised of the following: 

  • At least 6 currently enrolled Sacramento State students. 
  • A student director from Associated Students 
  • A student appointee from Student Organizations and Leadership, the Multi-cultural Center or the PRIDE Center
  • A staff representative from SHCS appointed by the Executive Director for Counseling and Health Services

The President or designee shall be responsible for ensuring that campus emergency plans include a provision for the training and assignment of SHCS staff in disasters that may require emergency medical services. 

  • The SHCS staff shall review and update SHCS medical disaster procedures as appropriate and update the campus emergency plan accordingly. 
  • The Executive Director of SHCS may make recommendations to the President (or designated representative) regarding the delivery of health services during emergency operations.

Procedures for Campus Health Oversight

Approved by Alexander Gonzalez, President

January 12, 2015