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Campus Oversight Policy for University Health Services | Policies | CSUSM

Campus Oversight Policy for University Health Services

Definition: The President (or designee), shall ensure appropriate oversight of all University health services. 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, 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.
Authority: The California State University Executive Order 814. The campus President is responsible for any amendment or interpretation of this policy.
Scope: Applies to all areas of the University.
Responsible Division: Student Affairs
Approval Date: 11/21/2007
Originally Implemented: 11/24/2003
Signature Page/PDF: View Signatures for Campus Oversight Policy for University Health Services Policy


Health services shall be defined as the assessment and treatment or referral for treatment of medical conditions provided by a department or program of Cal State San Marcos or one of its auxiliaries. Immunization administration and health promotion are considered health services. For Cal State San Marcos, the included organization is Student Health and Counseling Services and Athletic Medicine.

A. Each provider's role and responsibility are determined by their professional skills, competence, and credentials.

B. Determination of provider qualification will be guided by state law, California State University Classification and Qualification Standards, National Practitioner Data Bank review, professional references and accreditation agency guidelines.

C. Each health care provider:
  1. Meets the standards of practice for the services area.
  2. Practices within the scope of his/her licensure, certification, and training.
  3. Meets the requirements/minimum qualifications set forth by the California State University Board of Trustees and applicable Executive Orders.
  4. Possess and maintains a valid and relevant California professional license.
  5. Provide documentation of current license status consistent with the professional discipline to the appropriate Human Resources office.
  6. Consent to a confidential process by which external agencies are contacted to verify license, training, previous or current practice experience, and such other information relating to professional competencies.
D. 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 President or designee.

E. Where there are applicable standards, each area will establish or implement and comply according to the professional groups or accreditation body specific to their area.

F. Where appropriate, the provider of a service shall be licensed, certified, and trained within the applicable guidelines for the licensure or certification.

G. Written policies and procedures shall be maintained that define the scope of services and basic guidelines of practice.


A. All campus entities will ensure a clean, safe, functional and effective environment to reduce the risk of environmental spread of disease.

B. 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. A professional pharmacist shall evaluate the processes, procedures, and safeguards to insure compliance with applicable federal and state laws and regulations.

C. Medical equipment and/or devices used shall comply with appropriate safety standards and shall be inspected and calibrated as required by state or federal law or rule.

D. The Office of Risk Management and Safety shall establish procedures for the disposal of biohazardous waste generated in the course of the provision of medical services. Used needles, syringes, and the like shall be stored onsite in appropriate puncture and tamper proof containers containing the proper university labels. Paper and other medical trash shall be placed in appropriately identifiable bags/containers. Disposal of all medical waste shall be done consistent with state and federal laws.

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

F. The President or designee, in consultation with the Chief of University Police and the Office of Risk Management and Safety shall develop campus security policies specific to facilities in which health services are provided. Provisions for formal monitoring of such policies must be established. The monitoring process and results of such monitoring shall be reported the Chancellor.


A. Medical Records:

  1. Information shall be considered confidential and secured in compliance with state and federal laws (California Information Practices Act {Civil Code §1798.1 et seq}, Confidentiality of Medical Information Act {Civil Code §56 et seq}, & FERPA).
  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:
  • Name of the recipient (patient)
  • Date
  • Location
  • Health service provided
  • Name, signature, and professional discipline (i.e., MD, FNP, RN, etc.) of the provider(s).
B. Protection and Release of Medical Information
  1. Medical information is regarded as confidential, and thus is not part of the academic record except as specified in the Family Education Records Privacy Act (FERPA).
  2. Disclosures relating to the patients not covered by FERPA may only be made with the specific consent of the patient except for the purposes of treatment, payment, and healthcare operations and as excepted by law or court order.
  3. 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.
  4. No medical information shall be made available for marketing purposes, except when specifically approved by the patient.
  5. Medical information may be released to parents or other adult sponsors on unemancipated minors except where prohibited by law.
  6. Releases under subpoena or at the request of government agencies or law enforcement agencies shall be processed through the office of Risk Management and Safety.


A. When a campus activity engages in the provision of health services, the President or designee shall identify one individual as responsible for the oversight of the program. For Student Health and Counseling Center and for Athletic medicine, the Student Health and Counseling Center Director is the designated responsible individual.

B. All service areas shall engage in an ongoing, documented process of review and improvement of its offerings. This process shall include, bur 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. As outcome should be considered adverse if:
    a. The patient/client suffers physical, personal, or financial loss as the result of an action or inaction.
    b. The patient/client is harmed physically, psychologically, or financially by an assessment, treatment, or referral.
    c. The patient/client must seek treatment elsewhere due to an unplanned outcome of a service provided.
    d. The patient/client is apt to 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 timelines and appropriateness of its services.
D. Quality management and improvement records shall be safeguarded and are not subject to routine release, subject to the guidance of Staff Counsel.

E. Each service shall assess the timeliness and appropriateness of its services.

F. Each student health service will submit annual reports as required to the President or designee and to the Chancellor's Office.


A. The President or designee shall establish a Student Health Advisory Committee (SHAC). The committee shall be advisory to the President or designee and the Student Health Center.

B. The committee shall advise on:

a. The scope of service.
b. Delivery of health services.
c. Funding.
d. Other critical issues relating to campus health services.

C. Membership:

a. Students shall constitute a majority of membership.
b. Other members will include one (1) faculty and/or one (1) staff.
c. A representative of the Student Health Services.
d. A student shall chair the committee.