CALIFORNIA STATE UNIVERSITY, SAN BERNARDINO

CAMPUS HEALTH SERVICES OVERSIGHT POLICY

RECOMMENDED BY ADMINISTRATIVE COUNCIL:   February 9, 2004

APPROVED BY ALBERT K. KARNIG, PRESIDENT:   February 16, 2004

FOR INTERPRETATION OF THIS POLICY, PLEASE CONTACT:
    Office of Vice President for Student Affairs -- 909/880-5185

1. Overview/Purpose
   
   By Executive Order, the president (or designated representative) 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.  The intent is to assure compliance with relevant California State University policy, privacy practices, and federal, state and local laws.
   
   

2. Scope
   
   This policy applies to all California State University, San Bernardino 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 shall not apply to first aid administered on campus, except by departments or programs that otherwise are considered being health service entities.
   
   

3. Campus Health Services Oversight Committee (CHSOC)

1. Purpose:
   
   The purpose of CHSOC is to assist the campus president (or designated representative) to oversee and implement the Campus Health Services Oversight Policy.
   
   

2. Charge:
   
   The Committee shall provide advice to the president (or designated representative) that will help ensure that health services provided to any campus member through the Student Health Center and Psychological Counseling Center (SHCPCC), university athletic programs, academic programs, student programs and auxiliary organizations are in compliance with the CSU Chancellor's policies including Executive Order 814 and the CSUSB Campus Health Services Oversight Policy.  In particular, the Committee will be a valuable advisor on the scope of service(s), delivery, funding, and other critical issues relating to campus health services.  The Committee should identify costs (and sources of funds) associated with specific recommendations.
   
   

3. Membership:
   
   Although the membership of the CHSOC may change from time to time as needed, the regular members of the committee shall be comprised of the following:

• Director of SHCPCC

• Director of Human Resources

• Director of Athletics

• One physician from the Student Health Center

• Director, Community Counseling Center (Psychology Department)

• Director, Services to Students with Disabilities

• Coordinator, Nutrition and Food Sciences Program

• Chair, Nursing Department

• Director, University Police

• Directors of other campus health service-related programs

• Two students representing the Student Health Advisory Committee

In order to conduct special tasks or to adapt to changing campus health service provision, additional members (e.g., full-time faculty from health-related academic programs) of the Committee may be named by the president (or designated representative) or by the Committee.

4. Leadership:
   
   The Director of the SHCPCC will co-chair the CHSOC.  The president (or designated representative) will appoint a co-chair from the other members of the committee.  The appointed co-chair will serve a two-year term and can be re-appointed.
   
   
5. Operations:
   
   The Committee will operate under the CHSOC Operating Code which will be annually reviewed by the Committee membership.
   
   
6. Meetings:
   
   The CHSOC will meet at least four times each year:  Once during each quarter of the academic year and at least once during the summer.  More frequent meetings may be called as necessary.
   

4. Definition of Campus Health Services
   
   Campus health services shall be defined as the identification, assessment, treatment, and/or referral for any health conditions or concerns which are provided by a department, a program, or one of its auxiliaries, to any member of the campus community.  Immunization administration and health promotion are considered health services.  Included organizations are:
   

1. University SHCPCC
   
   
2. Athletic Medicine provided by any athletic staff
   
   
3. Health services rendered as part of an academic program and under the supervision of an appropriately qualified faculty member, e.g.:

1. Kinesiology Department
   
   
2. Any academic program that provides health services by grants or contract to the community.
   
   
3. Any other academic program that renders definitive health services, refers to community health resources, and/or documents health services rendered must self-identify in writing such services, on an annual basis, to the president or his designee.
   

4. Employee Assistance Program
   
   
5. Services for Students with Disabilities
   
   
6. Community counseling services provided to students in addition to those provided by the Psychological Counseling Center.
   
   
7. Any applied health services, health diagnoses, counseling or health assessments provided to CSUSB students as part of any academic or non-academic programs.
   

The above services and programs/departments, and any other similar medical services provided to CSUSB students, are deemed to be covered by the policies defined in this document.

5. Standards/Guidelines
   

1. Each provider's role and responsibility are determined by their professional skills, competence, and credentials.
   
   
2. 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.
   
   
3. Each health care provider must:
   

1. Meet the standards of practice for the service area.
   
   
2. Practice within the scope of his/her licensure, certification, and training.
   
   
3. Meet the requirements/minimum qualification set forth by the California State University Board of Trustees and applicable Executive Orders.
   
   
4. Possess and maintain a valid and relevant California professional license.

4. Unlicensed individuals providing health care (e.g., athletic trainers) must do so under the supervision of a physician or other appropriately licensed provider.  Such arrangements for supervision must be approved by the Director or designee of the SHCPCC.
   
   
5. 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.
   
   
6. Where appropriate, the provider of a service shall be licensed, certified, and trained within the applicable guidelines for the licensure or certification.
   
   
7. Written policies and procedures shall be maintained that define the scope of services and basic guidelines of practice.
   

6. Environmental Health, Safety, and Risk Management
   
   

1. All campus activities providing any form of health services to any CSUSB 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.
   
   
2. 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 processes, procedures, and safeguards to ensure compliance with applicable federal, local, and state laws and regulations.
   
   
3. 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 or rule.
   
   
4. The Office of Environmental Health and Safety (OEHS) shall establish and monitor procedures for the disposal of biohazard waste generated in the course of the provision of health services.  Used needles, syringes, and the like shall be stored on site in appropriate puncture and tamper proof containers.  Paper and other medical trash shall be placed in appropriately identifiable bags/containers.  Disposal of all health services waste shall be done 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 OEHS.
   
   
5. Campus entities shall consult with the Office of Risk Management to ensure adequate coverage for insurance and liability coverage.
   
   
6. The president (or designated representative), in consultation with the Director of Public Safety, shall develop campus security policies specific to facilities in which health services are provided.
   

1. Provisions for formal monitoring of the effect of such policies must be established and approved by the CHSOC.  The monitoring process and results of such monitoring shall be reported to the CHSOC, the president or his/her designee, and the CSU Chancellor.
   
   
2. Only those authorized by the SHCPCC Director shall have access to the facilities.  The Director of Public Safety shall, on a quarterly basis, provide the SHCPCC Director the control list for building access.
   
   
3. The SHCPCC Director, in consultation with the appropriate campus authority, shall authorize facility access at other than routine business hours.  An access list shall be maintained and approved by the SHCPCC Director and the CHSOC.
   
   
4. Others may access the facilities if health center staff members are present and medical records, equipment, and pharmaceuticals are secured.
   
   
5. The Athletic Director, when designated by the president, shall establish comparable procedures for the training room.
   
   
6. The president (or designated representative) shall likewise designate, as necessary, other campus facilities in which medical records, equipment, or pharmaceuticals are stored and assign security responsibilities appropriately.
   

7. Protected Health Information
   

1. The Medical Record
   

1. Information shall be considered confidential and should be secured in compliance with state and federal laws (Family Education, Records Privacy Act, Health Insurance Portability and Accountability Act, California Information Practices Act {Civil Code Sec 1798.1 et seq, and Confidentiality of Medical Information Act {Civil Code Sec 56 et seq} ), and other mandated laws or policies.
   
   
2. 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:
   
   

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

2. Protection and Release of Medical Information
   
   

1. 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.
   
   
2. For non-students, the provisions of HIPAA apply if the program is declared a health care component of the University; if not designated as being subject to HIPAA and/or if California law be more stringent, then California privacy laws shall apply.
   
   
3. Disclosures relating to patients generally may only be made with the specific consent of the patient except for those purposes as excepted by law or court order.
   
   
4. If subject to HIPAA, a notice of privacy practices must be provided by the health care component to each patient at the time of first visit or treatment and acknowledged in writing by the patient.
   
   
5. Incidental disclosure and use of medical information is not a violation of this procedure or applicable law so long as the medical information is protected by reasonable safeguards and a minimum necessary use standard is met.
   
   
6. No medical information shall be made available for marketing purposes.
   
   
7. 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).
   
   
8. 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.
   
   
9. Releases under subpoena or at the request of government agencies or law enforcement agencies shall be processed through the Vice President for Administration and Finance.
   
   
10. Medical information (i.e. medical records) shall be secured when not in use in either a locked room or locked containers in addition to being in a secured, i.e., locked building.  Access to such records shall be limited to the minimum necessary to accomplish the records maintenance function; the president or his designee shall establish such control measures as are necessary to protect such records in a consistent fashion anywhere in the University.  Positive control of records, when not stored, will be established.
    
    

8. Oversight

1. When a campus activity engages in the provision of health services, the president (or designated representative) shall identify one individual as responsible for the oversight of the program.
   
   

1. For the student health center, the Director, is the designated responsible individual.
   
   
2. The Athletic Director is responsible for the athletic medicine program; and shall designate in writing a physician to exercise medical oversight.  Policies and procedures for the athletic medicine program shall be in writing and approved by the designated physician.
   
   

2. 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 (licensed) pharmacist when medications are stored/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 (licensed) pharmacist.
   
   
3. All service areas shall engage in an ongoing, documented process of review and improvement of its offerings.  This process shall include, but need not be limited to:
   
   

1. Peer Review
   
   
2. A system for documenting and evaluating unusual occurrences.  Any adverse outcome of a health service provided shall be reported as soon as possible to the campus Risk Manager(s).  An outcome should be considered adverse if:
   
   

1. The patient/client reports physical, personal, or financial loss as the result of an action or inaction.
   
   
2. The patient/client reports harm physically, psychologically, or financially by an assessment, treatment or referral.
   
   
3. The patient and/or client must seek treatment elsewhere due to an unplanned outcome of a service provided.
   
   
4. The patient/client may file a claim against the University.
   
   

3. A regular review of its operation and its compliance with standards of operation and relevant campus, California State University, governmental, and ethical guidelines.
   
   
4. An assessment of the timeliness and appropriateness of its services.
   
   

9. Student Health Advisory Committee (SHAC)
   
   The president or designee shall establish a student health advisory committee.
   

1. The Committee shall be advisory to the president or designee and the Student Health Center.
   
   
2. The Committee shall advise on:
   
   

1. The scope of service
   
   
2. Delivery of health services and psychological counseling services
   
   
3. Funding
   
   
4. Other critical issues relating to campus health services
   

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

• One faculty member appointed by the Executive Committee of the Faculty Senate.
  
  
• Three undergraduate students and two graduate students appointed by the president of the Associated Students or designee.
  
  
• Two at-large student members appointed by the president of the Associated Students or designee.
  
  
• Two representatives of the Health Center staff, appointed by the Director of the Center.
  
  
• One representative from the Psychological Counseling Center appointed by the Director of that center.
  
  
• One representative, student or staff, appointed by the Director of the Office of Services to Students with Disabilities.  A student member is preferred.
  
  
• The Director and the Assistant Director of the Student Health Center (ex officio).
  
  

10. Coordination of health services between Student Health Center and the Department of Athletics.
    

1. Student athletes are regular students of the University and are therefore eligible for medical services from the SHCPCC.  The Department of Athletics may fund and/or provide additional medical services to student athletes, including but not limited to services from team physicians, trainers, and the training room.
   
   
2. As Athletics and SHCPCC share a mutual interest in the health of student athletes, it is understood that the following coordinating procedures and policies will apply:
   
   

1. Athletics shall, when referring a student athlete for supported services, ensure that an appropriate consent to disclose medical information is initiated and signed and dated by the student athlete and will specifically permit exchange of medical information between team physicians, trainers, and SHCPCC physicians and other SHCPCC clinical staff members as is necessary for the effective care of the student athlete.  Copies shall be provided to SHCPCC on an as-needed basis.
   
   
2. Coaches, administrators, and others who are not directly engaged in the treatment process have no right of access without patient 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 Department of Athletics and University procedures and CSU systems with due regard to the privacy of the individual.
   
   
3. Care rendered to student athletes by team physicians shall be documented and maintained by such means as is determined by Athletics.  However, any system of records shall meet or exceed that established for the SHCPCC.  A legible copy of such documentation, identifiable with the name of the student, the date of each treatment instance, and the name of the individual rendering medical care, shall be provided to SHCPCC for inclusion in the medical record of the student athlete to ensure continuity of the medical treatment effort.
   
   

3. Reimbursement for health services
   

1. When so agreed, Athletics shall pay SHCPCC fees and charges for services which otherwise would be the responsibility of the student athlete.  Student athletes eligible for paid services will be provided a "Treatment Release" which will identify the student athlete, the services to be paid, and will be signed and dated by an authorized individual.  The student athlete must present the form to SHCPCC at the time services are rendered.  Athletics shall be the sole authority to determine which services shall be paid for by Athletics; the student athlete shall be responsible for payment of any charges not paid for by Athletics.
   
   
2. Student costs for specified services in the SHCPCC will be paid monthly, in arrears, by Athletics on presentation of an SHCPCC invoice, with supplemental itemized listings of services rendered and the cost for each service attached.  Such medical services normally will consist of laboratory tests, x-rays, pharmaceuticals, and per item visit charges in effect during periods other than the regular academic semesters.  All charges will be at SHCPCC rates and charges in effect at the time the service is rendered.
   

4. Athletics will provide to SHCPCC on at least an annual basis a written listing by name and telephone number of team physicians, professional (regular staff) trainers, and student trainrs.
   
   
5. SHCPCC will honor prescriptions from team physicians and will provide copies of x-rays and clinical laboratory test results to the team physician or his 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.
   
   
6. Coordination of care will be routinely accomplished between SHCPCC clinical staff members and team physicians (or professional trainers when so designated).  The senior trainer or the trainer for each sport, as designated by Athletics, shall act as liaison between the SHCPCC and the team physician(s).  Transportation of an injured or ill student athlete to the SHCPCC shall be the responsibility of Athletics, and normally shall be preceded by a notification call in order to ensure that adequate staff and facilities are available.  SHCPCC shall notify Athletics in a timely fashion should certain services not be available and the expected duration of the non-availability.
   
   
7. SHCPCC medical care rendered to regular Athletics staff members shall be accomplished and reimbursed consistent with the University's policies on workers' compensation for initial evaluation and care of an on-the-job injury or illness, for immunization programs for infectious diseases, such as Hepatitis B, or for limited medical examinations relating to job function, such as DMV Class B Drivers' License examination.
   
   
8. SHCPCC medical care rendered to employees of the Athletic Corporation shall be subject to the policies and procedures of the Athletic Corporation and shall normally require prior clearance before care is rendered.
   
   
9. Student trainers who are regular students of the University are eligible for all SHCPCC services, subject to payment of the mandatory student health services fee.  In those instances when Athletics requests a special service and agrees to pay student costs for such a service, such as Hepatitis B Immunization, such requests should normally be in writing and in advance of the desired date of service.
   
   
10. In order to ensure effective coordination of services, SHCPCC staff members shall meet with Athletics team physicians and/or trainers on at least an annual basis or as necessary by mutual agreement.
    
    

11. Medical Disaster Planning
    

1. The Medical Disaster Planning Unit's primary responsibility is the development of the medical response plan for obtaining medical aid from every possible resource available.  This is to include the transportation of injured and/or ill incident personnel, as well as the preparation of reports and maintaining records for reimbursement of costs.  This is to be accomplished by using Standard Emergency Management System (SEMS).  SEMS is the emergency management organization required by California statute Government Code 8607(a) for emergency response and disaster management in multi-agency and multi-jurisdictional emergencies.
   
   
2. The president (or designated representative) shall be responsible for ensuring that campus emergency plans include a provision for the training and assignment of Student Health Center staff in disasters that may require emergency medical services.
   
   
3. The Student Health Center staff shall review medical disaster portions of the campus emergency plan annually.
   
   
4. The Director of the Student Health Center may make recommendations to the president (or designated representative) regarding staffing augmentations from other campus activities having medical professionals as well as mutual aid from other CSU campuses or in conjunction with the Director of Human Resources, recommend the training and composition of staffing teams to include any and all available health resources.
   
   

12. Required Reporting
    
    The campuswide Health Oversight Committee shall complete and submit to the president:
    
    

1. An annual campus survey assessing the status of all health services provided to the campus including a written listing of all health services provided and areas of potential risk.
   
   
2. Annual comparative performance measures in the form and manner developed by the CSU systemwide advisory committee to the Chancellor on health services.
   
   
3. Submit reports of any and all accreditation bodies if performed during the year.
   
   
4. Submit copies of revisions to the campus oversight policies for approval by the president.
   

13. Approval
    
    This policy shall be reviewed by the CSUSB Administrative Council and approved by the president.
    
    
14. Amendments
    
    

1. Any individual, office, department, service or campus member affected by this policy will be able to submit recommended amendments to the policy.
   
   
2. The CHSOC will be responsible for soliciting, receiving, and reviewing all recommended changes to the Campus Health Services Oversight Policy.
   
   
3. Recommendations must be made in writing and provide specific revised or new language.  Recommendations must be provided to the CHSOC at least two weeks prior to the next meeting of the CHSOC.  The CHSOC will carefully review and edit the recommended changes and, if approved, will forward their recommendations on to the president (or designated representative).  Recommended changes must be approved by a quorum of the CHSOC members.  The Co-Chair will only vote in cases of a tie.  Recommendations not approved will be returned to the recommending party with a brief explanation as to the reasons.
   
   
4. The CHSOC will forward approved recommendations and changes to the president (or designated representative).  When a designated representative is present, this representative will review CHSOC's recommendations and forward them to the president.
   
   
5. Recommended changes reviewed by the Administrative Council and approved by the president will go into effect as soon as feasible.

RETURN TO UNIVERSITY POLICIES
AND PROCESSES INDEX