Ohio Admin. Code 5122-1-04 - Access to confidential personal information
(A) The purpose of this rule is to establish
the requirements for regulating access to the confidential personal information
that is maintained by the Ohio department of mental health and addiction
services.
(B) For the purposes of
administrative rules promulgated in accordance with section
1347.15
of the Revised Code, the following definitions apply:
(1) "Access" when used in this rule as a noun
means an instance of copying, viewing, or otherwise perceiving.
"Access" when used in this rule as a verb means to copy, view, or otherwise perceive.
(2)
"Acquisition of a new computer system" means the purchase of a "computer
system," as defined in this rule, that is not a computer system currently in
place nor one for which the acquisition process has been initiated as of the
effective date of the department rule addressing requirements in section
1347.15
of the Revised Code.
(3) "Computer
system" means a "system," as defined by section
1347.01
of the Revised Code, that stores, maintains, or retrieves personal information
using electronic data processing equipment.
(4) "Confidential personal information" (CPI)
has the meaning as defined by division (A)(1) of section
1347.15
of the Revised Code and identified by rules promulgated by the department in
accordance with division (B)(3) of section
1347.15
of the Revised Code that reference the federal or state statutes or
administrative rules that make personal information maintained by the
department confidential.
(5)
"Department" means the Ohio department of mental health and addiction
services.
(6) "Employee" means each
Ohio department of mental health and addiction services employee regardless of
whether the employee holds an elected or appointed office or position within
the department.
(7) "Incidental
contact" means contact with the information that is secondary or tangential to
the primary purpose of the activity that resulted in the contact.
(8) "Individual" means a natural person or
the natural person's authorized representative, legal counsel, legal custodian,
or legal guardian.
(9) "Information
owner" means the individual appointed in accordance with division (A) of
section
1347.05
of the Revised Code to be directly responsible for a system.
(10) "Person" means a natural
person.
(11) "Personal information"
has the same meaning as defined in division (E) of section
1347.01
of the Revised Code.
(12) "Personal
information system" means a "system" that "maintains" "personal information" as
those terms are defined in section
1347.01
of the Revised Code. "System" includes manual and computer systems.
(13) "Research" means a methodical
investigation into a subject.
(14)
"Routine" means commonplace, regular, habitual, or ordinary.
(15) "Routine information that is maintained
for the purpose of internal office administration, the use of which would not
adversely affect a person" as that phrase is used in division (F) of section
1347.01
of the Revised Code means personal information relating to employees and
maintained by the agency for internal administrative and human resource
purposes.
(16) "System" has the
same meaning as defined by division (F) of section
1347.01
of the Revised Code.
(17) "Upgrade"
means a substantial redesign of an existing computer system for the purpose of
providing a substantial amount of new application functionality, or application
modifications that would involve substantial administrative or fiscal resources
to implement, but would not include maintenance, minor updates and patches, or
modifications that entail a limited addition of functionality due to changes in
business or legal requirements.
(C) Procedures for accessing confidential
personal information for personal information systems, whether manual or
computer systems.
(1) Personal information
systems of the department are managed on a "need-to-know" basis whereby the
information owner determines the level of access required for a department
employee to fulfill the employee's job duties. The determination of access to
confidential personal information shall be approved by the employee's
supervisor and the information owner prior to providing the employee with
access to confidential personal information within a personal information
system. The department shall establish procedures for determining a revision to
an employee's access to confidential personal information upon a change to that
employee's job duties including, but not limited to, transfer or termination.
Whenever an employee's job duties no longer require access to confidential
personal information in a personal information system, the employee's access to
confidential personal information shall be removed.
(2) Individual's request for a list of
confidential personal information.
Upon the signed written request of any individual for a list of confidential personal information about the individual maintained by the department, the department shall do all of the following:
(a) Verify the identity of the individual by
a method that provides safeguards commensurate with the risk associated with
the confidential personal information;
(b) Provide to the individual the list of
confidential personal information that does not relate to an investigation
about the individual or is otherwise not excluded from the scope of Chapter
1347. of the Revised Code; and
(c)
If all information relates to an investigation about that individual, inform
the individual that the department has no confidential personal information
about the individual that is responsive to the individual's request.
(3) Notice of invalid access.
(a) Upon discovery or notification that
confidential personal information of a person has been accessed by an employee
for an invalid reason, the department shall notify the person whose information
was invalidly accessed as soon as practical and to the extent known at the
time. However, the department shall delay notification for a period of time
necessary to ensure that the notification would not delay or impede an
investigation or jeopardize homeland or national security. Additionally, the
department may delay the notification consistent with any measures necessary to
determine the scope of the invalid access, including which individuals'
confidential personal information invalidly was accessed, and to restore the
reasonable integrity of the system.
"Investigation" as used in this paragraph means the investigation of the circumstances and involvement of an employee surrounding the invalid access of the confidential personal information. Once the department determines that notification would not delay or impede an investigation, the department shall disclose the access to confidential personal information made for an invalid reason to the person.
(b) Notification provided by the
department shall inform the person of the type of confidential personal
information accessed and the date(s) of the invalid access.
(c) Notification may be made by any method
reasonably designed to accurately inform the person of the invalid access,
including written, electronic, or telephone notice.
(4) Appointment and duties of a data privacy
point of contact.
(a) The director of the
department shall designate an employee of the department to serve as the data
privacy point of contact.
(b) The
data privacy point of contact shall work with the chief privacy officer within
the Ohio department of administrative services office of information technology
to assist the department with both the implementation of privacy protections
for the confidential personal information that the department maintains and
compliance with section
1347.15
of the Revised Code and the rules adopted thereunder.
(c) The data privacy point of contact shall
ensure the timely completion of the "privacy impact assessment form" developed
by the Ohio department of administrative services office of information
technology.
(D) Valid reasons for accessing confidential
person information.
Pursuant to the requirements of division (B)(2) of section 1347.15 of the Revised Code, this rule contains a list of valid reasons directly related to the department's exercise of its powers or duties, for which only employees of the department may access confidential personal information regardless of whether the personal information system is a manual system or computer system.
Performing the following functions, as part of the employee's assigned duties on behalf of the department, constitute valid reasons for authorized employees of the department to access confidential personal information:
(1) Responding to a
public records request;
(2)
Responding to a request from an individual for the list of confidential
personal information the department maintains on that individual;
(3) Administering a constitutional provision
or duty;
(4) Administering a
statutory provision or duty;
(5)
Administering an administrative rule provision or duty;
(6) Complying with any state or federal
program requirements;
(7)
Processing or payment of claims or otherwise administering a program with
individual participants or beneficiaries;
(8) Auditing purposes;
(9) Licensure or certification
processes;
(10) Investigation or
law enforcement purposes;
(11)
Administrative hearings;
(12)
Litigation, complying with an order of the court, or subpoena;
(13) Human resource matters (e.g., hiring,
promotion, demotion, discharge, salary/ compensation issues, leave
requests/issues, time card approvals/issues);
(14) Complying with an executive order or
policy;
(15) Complying with a
department policy or a state administrative policy issued by the Ohio
department of administrative services, the office of budget and management or
other similar state agency;
(16)
Complying with a collective bargaining agreement provision; or
(17) Research in the furtherance of
department specific programs in so far as allowed by statute.
(E) The following federal statutes
or regulations or state statutes and administrative rules make personal
information maintained by the department confidential and identify the
confidential personal information within the scope of rules promulgated by this
department in accordance with section
1347.15
of the Revised Code:
(1)
5 U.S.C.
552a. (social security numbers).
(2)
42
U.S.C. 1320d and 45 C.F.R. parts 160 and 164
(protected health information under the Health Insurance Portability and
Accountability Act).
(4)
42 C.F.R.
482.13 (patient records).
(5)42 C.F.R. Part 2 (confidentiality of
alcohol and drug abuse patient records).
(6)
42 U.S.C.
1396a(a) (medicaid
records).
(7) Sections
5119.27
and
5119.28
of the Revised Code (confidentiality of records).
(8) Sections
2305.24,
2305.25,
2305.251,
2305.252,
2305.253
and
5122.32
of the Revised Code (quality assurance and peer review records).
(9) Section
5122.31 of the
Revised Code (patient certificates, applications, records, and
reports).
(10) Section
5122.311
of the Revised Code (notification of bureau of criminal identification and
investigation of adjudication of mental illness).
(11) Paragraph (I) of rule
5122-1-31
of the Administrative Code (voter registration of consumers and absentee voting
assistance in behavioral healthcare organizations of the integrated behavioral
healthcare system).
(12) Paragraph
(C
D )(3) of
rule
5122-2-25
of the Administrative Code (morbidity,
and mortality, and
sentinel events).
(13)
Paragraph (D)(4)(e) of rule
5122-3-13
of the Administrative Code (incident reports).
(14) Paragraph (C)(7) of rule
5122-30-22
of the Administrative Code (resident written information and
communications).
(F) Restricting and logging access to
confidential personal information in computerized personal information systems.
For personal information systems that are computer systems and contain confidential personal information, the department shall do the following:
(1) Access restrictions.
Access to confidential personal information that is kept electronically shall require a password or other authentication measure.
(2) Acquisition of a new computer
system.
When the department acquires a new computer system that stores, manages or contains confidential personal information, the department shall include a mechanism for recording specific access by employees of the department to confidential personal information in the system.
(3) Upgrading existing computer
systems.
When the department modifies an existing computer system that stores, manages or contains confidential personal information, the department shall make a determination whether the modification constitutes an upgrade. Any upgrades to a computer system shall include a mechanism for recording specific access by department employees to confidential personal information in the system.
(4) Logging
requirements regarding confidential personal information in existing department
computer systems.
(a) The department shall
require department employees who access confidential personal information
within computer systems to maintain a log that records their access.
(b) Access to confidential information is not
required to be entered into the log under the following circumstances:
(i) The department employee is accessing
confidential personal information for official department purposes, including
research, and the access is not specifically directed toward a specifically
named individual or a group of specifically named individuals.
(ii) The department employee is accessing
confidential personal information for routine office procedures and the access
is not specifically directed toward a specifically named individual or a group
of specifically named individuals.
(iii) The department employee comes into
incidental contact with confidential personal information and the access of the
information is not specifically directed toward a specifically named individual
or a group of specifically named individuals.
(iv) The department employee accesses
confidential personal information about an individual based upon a request made
under either of the following circumstances:
(a) The individual requests confidential
personal information about himself/herself
(b) The individual makes a request that the
department takes some action on that individual's behalf and accessing the
confidential personal information is required in order to consider or process
that request
(v) For
purposes of this paragraph, the department may choose the form or forms of
logging, whether in electronic or paper formats.
(5) Log management.
The department shall issue a policy that specifies the following:
(a) Who shall maintain the
log;
(b) What information shall be
captured in the log;
(c) How the
log is to be stored; and
(d) How
long information kept in the log is to be retained.
(6) Nothing in this rule limits the
department from requiring logging in any circumstance that it deems
necessary
Notes
Promulgated Under: 119.03
Statutory Authority: 1347.15, 5119.10
Rule Amplifies: 1347.01, 1347.05, 1347.15, 5119.01, 5119.10, 5119.27, 5119.28
Prior Effective Dates: 09/09/2010, 12/14/2014
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.