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PURPOSE:

Executive Order 814 states that "The President or designee shall ensure appropriate oversight of all university health services." This policy will outline standards and guidelines for the oversight and provision of health services to students, employees, and visitors at CSU Northridge with the intent of ensuring compliance with CSU Northridge policies, and state and federal laws.

SCOPE:

This policy applies to all CSU Northridge departments, programs, and auxiliaries that provide health services. Nothing in this policy shall supersede CSU Trustees' Policy, applicable Executive Orders, or applicable provisions in CSU Collective Bargaining Agreements. This policy will not apply to basic first-aid administered on campus by departments, programs, or parties that are not considered identified providers of health services.

DEFINITION OF HEALTH SERVICES:

Health services are defined as the assessment, treatment, or referral for treatment of medical and health related conditions and include immunizations and health education programs.

A. Departments or programs which currently provide health services to CSU Northridge:

1. The Klotz Student Health Center (SHC)

2. University Counseling Services/Employee Assistance Program (UCS/EAP)

3. The Department of Kinesiology/Center of Achievement for the Physically Disabled (CAPD)

4. The Department of Physical Therapy

5. The Department of Communication Disorders and Sciences/Language, Speech and Hearing Center (LSHC)

6. The Office of Human Resource Services

7. The Department of Public Safety

B. 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 her designee and to the Campus Health Services Oversight Committee.

C. The following Departments/programs provide education in support of health services and referral to campus health services:

1. Center on Disabilities/Students with Disabilities Resources

2. National Center on Deafness

3. Office of Human Resource Services

GUIDELINES & STANDARDS FOR HEALTHCARE PROVIDERS:

A. Only those providers 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 a combination of state law, CSU Professional Classifications and Qualification Standards, National Practitioner Data Bank review, professional references, and accreditation agency guidelines. The President and/or her designee, in consultation with the Office of Human Resource Services, is responsible for credentialing providers of health care.

1. The Office of Human Resource Services will provide initial review of all applications to ensure CSU Professional Classifications and Qualification Standards are met.

2. At CSU Northridge, the designee to further credential providers of health care is the Director of the SHC or the Chair of the Department for which the person is assigned. Credentials for all licensed CSU Northridge health care providers will be reviewed annually by the Klotz Student Health Center Credentialing Committee or designee as noted below. Each licensed health care provider must:

a. Meet the qualifications for practice in the service area.

b. Possess and maintain a valid and relevant California license.

c. Practice within the scope of his/her licensure.

d. Meet the requirements/minimum qualifications set forth by the CSU Board of Trustees.

e. Additionally, the provider must consent to the confidential review of his/her licensure by the Credentialing Committee or designee which may include the confidential contact of external agencies to confirm professional experience, history, and expertise.

f. At CSU Northridge, the Klotz Student Health Center Credentialing Committee will annually credential:

i. Medical Doctors, including Athletic Physicians

ii. Nurse Practitioners

iii. SHC Physical Therapists

iv. SHC Radiology Technicians

v. SHC Laboratory Technologists

vi. SHC Pharmacists

vii. Nurses (RN and LVN)

g. The Department of Physical Therapy will credential Department Physical Therapists.

h. The Department of Communication Disorders and Sciences will credential licensed Speech-Language Pathologists and Audiologists who work at the Language, Speech and Hearing Center.

3. Unlicensed providers providing health care in the Department of Athletics such as athletic trainers must do so under the supervision of a licensed provider such as the Team Physician. Arrangements for supervision must be approved by the SHC Director and the Director of Athletics and/or their designees.

a. The Team Physician(s) will be responsible for the medical oversight of the athletic medicine program.

b. The Team Physician and the Director of Athletics and/or his designee will develop and maintain policies and procedures that define and guide the scope of practice of health services by athletic trainers, student trainees, and student assistants.

c. Qualifications, experience, and performance of trainers must be reviewed annually by the Team Physician and the Head Trainer.

4. Unlicensed providers providing health care in the Center of Achievement for the Physically Disabled (CAPD) must do so under the supervision of the CAPD Director(s) designated by the Chair of the Department of Kinesiology.

a. Each director is a full-time faculty member with the Department of Kinesiology and possesses a Ph.D. with extensive backgrounds in his/her designated areas.

i. The current land-based director is a Certified Athletic Trainer (CAT) and Certified Adapted Physical Education teacher (CAPE). The current aquatic-based director is certified in aquatic therapy by the Aquatic Therapy and Rehabilitation Institute (ATRI) and possesses a Risk Awareness/Safety Training for Aquatic Therapy & Rehabilitation Practitioners. Both directors are certified in CPR.

b. Part-time Lecturers and Graduate Teaching Assistants must possess a Bachelor of Science degree in Kinesiology, current CPR/First-Aid certification, automatic external defibrillator (AED) training, and be currently enrolled and meeting the minimum requirements for the graduate program.

c. Annual review of the credentials of Part-time Lecturers and Graduate Teaching Assistants will be conducted by the Directors of the CAPD in accordance with Department Policies and Procedures.

ENVIRONMENTAL HEALTH, SAFETY & RISK MANAGEMENT:

A. All campus activities providing health services will provide a safe environment to reduce the risk of illness or injury. Definition of safe environment and policies for its implementation may include guidelines and requirements from:

B. Campus units providing health services should consult with the Office of Risk Management to ensure adequate coverage for potential risk and liability.

C. Campus units providing health services should consult with PPM and Public Safety to ensure adequate security of facilities providing health services.

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

1. Pharmacy

2. Medical Records

3. Facilities that contain protected health information (see below) and/or prescription drugs.

PROTECTED HEALTH INFORMATION:

A. The Medical Record

1. Information shall be considered confidential and should be kept confidential and secure in compliance with state and federal laws including FERPA and HIPAA, California Information Practices Act (Civil Code 1798.1 et seq.), and Confidentiality of Medical Information Act (Civil Code 56 et seq.)

B. Protection and Release of Medical Information

1. Medical information is not part of the academic record except as specified in FERPA.

2. For non-students, the provisions of HIPAA and/or California law (whichever is strictest) will apply.

3. Procedures for protection and release of Personal Health Information for the SHC are outlined in the SHC HIPAA Policies and Procedures. Standards for other Departments should remain equal to or more stringent as appropriate to these policies.

ADVERSE OUTCOME:

Any adverse outcome of a health service provided by CSU Northridge shall be reported as soon as possible to the Office of Risk Management. An outcome should be considered adverse if:

A. The client suffers physical, personal, or financial loss as the result of an action or inaction.

B. The client is harmed physically, psychologically, or financially by the services provided.

C. The client is apt to file a claim against the University.

OVERSIGHT:

A. When a campus entity engages in the provision of health services, the President or her designee shall identify the person or agency responsible for the oversight of the health services.

B. At CSUN, the responsibility for oversight of campus health services has been as

C. For individual units providing health services:

1. For the SHC, the Director

2. For UCS, the Director

3. For Public Safety, the Chief of Police

4. For Athletics, the Director and Team Physician

5. For Physical Therapy, the Chair

6. For Kinesiology, the Chair or designee

7. For Human Resource Services, the Director or designee

8. For Communication Disorders and Sciences, the Chair

D. Control and dispensing of prescription drugs on all campus departments will continue to be supervised by the SHC pharmacist, a licensed professional pharmacist. The SHC pharmacist will consult annually and as needed with the Athletic Department and any other Department providing prescription drugs and/or dispensing over the counter medications to ensure compliance with SHC Policies and Procedures regarding prescription drugs and with California and Federal law.

E. All areas that provide health services will engage in continuous quality improvement efforts and regular assessments to monitor compliance with appropriate industry and professional standards. These include:

1. Audits/surveys by responsible administrators or supervisors

2. Audits/surveys by the Campus Health Services Oversight Committee

3. Peer reviews

4. Surveys/audits from the CSU Northridge or the CSU

5. Audits from regulatory agencies

6. Audits/reviews by accreditation agencies

7. Audits by the CSU Northridge Office of Risk Management

STUDENT HEALTH ADVISORY COMMITTEE:

A. The President or designee will establish a student health advisory committee.

B. The committee shall be advisory to the President or designee and the Student Health Center.

C. The Committee shall advise on:

1. The scope of services

2. The delivery of health services

3. Funding issues

4. Other critical issues relating to campus health services

D. Membership

1. Students will constitute a majority of the membership.

2. Other ex-officio members may include faculty and staff.

3. One member will be the SHC Director

4. One faculty advisor

5. A student will chair the committee

MEDICAL DISASTER PLANNING:

A. The President or her Designee shall be responsible for ensuring that campus emergency plans include SHC staff in training about emergency operations and assignment to the emergency operations center.

B. The Director, SHC will review the campus emergency procedures with her staff annually.

C. The Director, SHC, may make recommendations to the President or her designee regarding the delivery of health services during emergency operations.

REQUIRED REPORTING:

A. Complete and submit the annual campus survey assessing potential risk to the CSU.

1. Includes a written listing/update of health services approved by the President or her designee provided by all campus departments.

B. Participate in CSU Benchmarking and Customer Satisfaction Surveys.

C. Submit reports by accreditation agencies if performed during the year.

D. Submit copies of campus oversight policies when approved by the President.

Approved by the President