Chapter 5122:2-1 Community Mental Health Board Operations

5122:2-1-02 Board client rights and grievance procedure.

(A) The purpose of this rule is to describe the role and responsibilities of community mental health boards in the client rights and grievance procedures.

(B) The provisions of this rule are applicable to each community mental health board. In addition, the provisions of rule 5122-26-18 of the Administrative Code are also applicable to each community mental health board which itself provides mental health services when permitted to do so in accordance with division (A)(8)(b) of section 340.03 of the Revised Code.

(C) Definitions.

(1) "Client rights officer" means the individual designated by a mental health agency or board with responsibility for assuring compliance with the client rights and grievance procedure rule as implemented within each agency or board. For these purposes the individual holds the specific title of client rights officer.

(2) "Contract agency" means a public or private service provider with which a community mental health board enters into a contract for the delivery of mental health services. A board which is itself providing mental health services is subject to the same requirements and standards which are applicable to contract agencies, as specified in rule 5122:2-1-05 of the Administrative Code.

(3) "Grievance" means a written complaint initiated either verbally or in writing by a client or by any other person or agency on behalf of a client regarding denial or abuse of any client's rights.

(4) "Services" means the complete array of professional interventions designed to help a person achieve improvements in mental health such as counseling, individual or group therapy, education, community psychiatric supportive treatment, assessment, diagnosis, treatment planning and goal setting, clinical review, psychopharmacology, discharge planning, professionally-led support, etc.

(D) Community mental health board procedure.

(1) Each community mental health board shall assure in its community plan that each contract agency has a grievance procedure in place which meets the requirements of rule 5122-26-18 of the Administrative Code. Each community mental health board shall recognize that, for an agency accredited and granted deemed status by the Ohio department of mental health in accordance with rule 5122-25-03 of the Administrative Code, the requirements of rule 5122-26-18 of the Administrative Code are met by agency conformance to its accrediting body standards.

(2) Each community mental health board must establish a procedure for addressing client rights complaints, including, when applicable, complaints initiated in accordance with rule 5122-30-22 of the Administrative Code on behalf of a resident of a residential facility. This procedure must include:

(a) Provision for accessing agency information relevant to the complaint;

(b) Provision of written copy of the board's grievance procedure to be available on request;

(c) Specification of time lines for a resolution of the grievance, not to exceed twenty working days from the date the grievance is filed;

(d) Provision for written notification and explanation of the resolution to be provided to the client, or to the griever if other than the client, with the client's permission;

(e) A statement regarding the option of the griever to further grieve with any or all of the following: Ohio department of mental health, Ohio legal rights service, U.S. department of health and human services. Appropriate professional licensing or regulatory boards' relevant names, addresses, and telephone numbers shall be included; and

(f) Provision for providing, upon request, relevant information about the grievance to one or more of the organizations specified in this paragraph to which the griever has initiated a complaint.

(E) Implementation and monitoring.

(1) Any board may accomplish its responsibilities in regard to the provisions of this rule and rule 5122-26-18 of the Administrative Code through utilization of its own staff or board members as appropriate, or through agreement with outside staff, agencies, or organizations, except that:

(a) Each board must assure prompt accessibility of the client rights officer.

(b) The utilization of outside persons must be clearly explained to clients, applicants, and grievers.

(2) The community mental health board shall also keep records of grievances it receives, the subject of the grievances, and the resolution of each, and shall assure the availability of these records for review by the department of mental health upon request. The board shall summarize annually its records to include number of grievances received, types of grievances, and resolution status.

(3) The department of mental health may periodically review the implementation of client rights policy and grievance procedures in each board area. Each board shall maintain a client rights policy and grievance procedure that is approved by the department of mental health. Subsequent substantive changes to such written policy and procedure shall be submitted to and approved by the department before enactment.

Replaces: 5122:2-1-02

Effective: 03/01/2012
R.C. 119.032 review dates: 03/01/2017
Promulgated Under: 119.03
Statutory Authority: 5119.61(A) , 5119.611 , 5119.613
Rule Amplifies: 5119.61(A) , 5119.611 , 5119.613
Prior Effective Dates: 4-9-1987

5122:2-1-03 County withdrawal from a joint-county community mental health board.

(A) The purpose of this rule is to establish the criteria and procedures for department of mental health authorization of the withdrawal by one or more board(s) of county commissioners from participation in a joint-county community mental health board.

(B) The provisions of this rule are applicable to all counties which participate in joint-county community mental health boards and particularly to each board of county commissioners which proposes to withdraw from a joint-county board.

(C) Procedures for requesting withdrawal.

(1) The board(s) of county commissioners of the county or counties requesting withdrawal shall submit to the director of the department of mental health and to the commissioners and mental health boards of each county in the joint-county board a resolution of the county commissioners requesting withdrawal together with a comprehensive written plan which shall include:

(a) Reasons for requesting such withdrawal;

(b) Description of the proposed new board service district and a map showing all relevant civil subdivisions, major lines of transportation, and location of mental health, health, and social service agencies in the proposed new board district to be comprised of or to include the withdrawing county(ies);

(c) Analysis and projection of the demographic and organizational elements to be affected including

(i) Projection, for at least four years from the proposed first year, of the populations in the proposed new and remaining board service districts, respectively, and

(ii) Identification of any existing contractual networks of mental health service programs which cross county boundaries and which would be disrupted if the proposed withdrawal occurs; and if a disruption is contemplated, a plan to assure continued service to clients must be included in the general plan;

(d) Evidence of the adequacy of community interest and of potential resources in the proposed new board service district, including the endorsement of civic and professional leaders and the adequacy of funding resources within the proposed new board service district, to support the organization and delivery of mental health services and programs which meet at least the minimum program standards of the department, including services to client population groups in the district that are designated by the department for high priority (such as the severely mentally disabled population group);

(e) Evidence that relevant community organizations, including at least all mental health, health, and social service agencies within the proposed new board service district, have been informed in writing of the proposed new board service district, its population and funding resources in relation to ability to provide needed services in accordance with the approved board comprehensive annual plan as required by section 340.03 of the Revised Code, and that these agencies have been invited to submit written comments to the board(s) of county commissioners in the proposed new board service district; and

(f) Evidence that a public hearing has been announced to all relevant agencies and to the general public within the proposed new board service district to be comprised of or to include the withdrawing county(ies), that such a public hearing has been conducted, and evidence of all written comments and other testimony received.

(g) Evidence that any county withdrawing from a joint-county board would continue to have levied against its tax list and duplicate any tax levied by the district during the period in which the county was a member of the joint-county board until such time as the levy expires or is renewed or replaced.

(h) Evidence of the provision for the equitable adjustment and division of all mental health services, assets, property, debts, and obligations, if any, of the joint-county district.

(D) Review by the department

(1) On receipt of the written proposed plan by the department, the director shall consider the request for withdrawal to assure:

(a) Compliance with all required standards and procedures in paragraph (C) of this rule;

(b) That relevant organizations and the general public have had the opportunity for comment and that all substantive, relevant questions, issues, and complaints have been appropriately resolved;

(c) That the remaining county or counties from which the withdrawal is proposed are able to assure continuation of services and programs which meet at least minimum program standards of the department.

(2) However, if substantive issues have not been resolved, or the proposed plan is not generally endorsed, or if the director has reason to believe the proposed plan is not in the best interest of the citizens of the county or the currently existing district, the director may, within thirty days of receipt of the proposed plan, request that a hearing be held to examine the relevant facts and opinions in order to make a decision. The hearing process shall be as follows:

(a) Reasonable public notice shall be given prior to the date set for the hearing and shall include:

(i) A statement that the department of mental health will hold a hearing on the proposed plan for withdrawal of one or more county(ies) from a joint-county district, and

(ii) The date, time and place of the hearing. All efforts will be made to hold the hearing in the county(ies) requesting withdrawal.

(b) On the date, time and place designated in the notice, the department of mental health will conduct a hearing at which any person or representative of any organization affected by the proposed action of the county may appear and be heard in person. Written or oral comment may be provided.

(c) The director shall designate a hearing officer to preside at said hearing. Such officer shall review the testimony and make a recommendation within thirty days to the director.

(3) The director shall notify the requesting board(s) of county commissioners of the department's approval or disapproval of the proposed plan in writing within sixty days after the department's receipt of the proposed plan for withdrawal, or within sixty days after the date of the hearing.

(4) No county participating in a joint-county community mental health service district may withdraw therefrom without the consent of the director nor earlier than one year after the submission of such resolution unless all of the participating counties agree to an earlier withdrawal.

Effective: 03/22/2012
R.C. 119.032 review dates: 12/30/2011 and 03/22/2017
Promulgated Under: 119.03
Statutory Authority: 340.01 , 5119.01 , 5119.61
Rule Amplifies: 340.01 , 5119.01 , 5119.61
Prior Effective Dates: 5/1/1968, 9/24/1984

5122:2-1-04 Department of mental health and addiction services appointments to boards.

(A) Purpose. The purpose of this rule is to establish a procedure for the Ohio department of mental health and addiction services (OhioMHAS) appointment of members of boards established pursuant to section 340.02 of the Revised Code, including reasonable notification of the interested public.

(B) "Board" for the purposes of this rule means any community mental health board; alcohol, drug addiction, and mental health services board; alcohol and drug addiction services board; or any other board established pursuant to section 340.02 of the Revised Code.

(C) Procedure

(1) When a vacancy becomes available for a department appointment or reappointment to a board, the board shall notify the OhioMHAS office of community support.

(2) The board may use public notification through posting, media, etc., to assure reasonable notification of the interested public. Any such notification shall include:

(a) Eligibility requirements for board membership under section 340.02 of the Revised Code;

(b) Duties and responsibilities of a board member as defined by statute;

(c) Length of the term of the vacancy being filled;

(d) Specific requirements for the board vacancy which is under consideration, if such requirements are present;

(e) Procedure and time limits for application;

(f) Process of obtaining state application form for appointment;

(g) Application and selection procedure as described in paragraph (B)(3) of this rule.

(3)

(a) Applications shall be prepared on the form provided by OhioMHAS, which shall include the board being applied for, appointment type, name of applicant, address, county of residence, education, experience, any applicable licensing information, a personal statement, demographic information, the applicant's signature, and the opportunity for the board to recommend the appointment and request waiver of appointment types.

(b) The receipt of applications, review and screening of applications, and interviewing of applicants may be delegated upon the discretion of the director of OhioMHAS. Notice of this delegation of authority shall be given to the board in written form with directions for forwarding to the department the results of these activities.

(c) The director, or the director's designee, will evaluate eligible candidates with the following priorities:

(i) Statutory requirements regarding the appointment ;

(ii) Effort to balance the composition of the board.

(D) The names, occupations, and length of service of all current board members at the time of adoption of this rule shall be forwarded to the department as of the effective date of this rule. An updated list forwarded to the department will be required when any appointments are requested.

Effective: 12/19/2013
R.C. 119.032 review dates: 10/02/2013 and 12/19/2018
Promulgated Under: 119.03
Statutory Authority: 340.02
Rule Amplifies: 340.02
Prior Effective Dates: 5/1/68, 10/14/82

5122:2-1-05 Community mental health board operation of mental health services or facilities.

(A) The purpose of this rule is to establish the requirements and procedures for department of mental health authorization of a community mental health board to operate a mental health service or facility.

(B) The provisions of this rule apply to any mental health service or activity specified in divisions (A) to (S) of section 340.09 of the Revised Code, or to any facility in which such services are provided, and which operate under contract with the community mental health board.

(C) Definitions

(1) "Director" means the chief executive and administrative officer of the Ohio department of mental health.

(2) "Emergency" means the imminent risk of a severe disruption or discontinuation of direct client services. For example, the sudden and unanticipated loss of funding or the loss of key staff may create a severe disruption or discontinuation of services.

(3) "Facility" means a building, structure or other improvement, equipment, and real property and interests in real property.

(4) "Operation of services, or facilities" means decision making or control and influence over decision making in the management or performance of a service, or facility.

(D) Section 340.03 of the Revised Code requires that mental health services be delivered by agencies under contract with a community mental health board. Services may be directly provided by a community mental health board only in the exceptional circumstances described in section 340.03 of the Revised Code.

(E) In any size service district, a board may operate a mental health service or facility in an emergency to provide essential services upon the prior approval of the director. The request for approval shall include:

(1) Evidence of the existence of the emergency as defined in paragraph (C)(2) of this rule.

(2) Evidence that there is no other feasible method for providing the service or facility.

(3) The projected time period during which the board intends to operate the serviceor facility.

(4) Assurance of the prompt development of a plan for ensuring that another agency will assume responsibility for operating the service or facility within one year.

(5) The operating plan for board provision of the service or facility.

(F) In any service district with a population of at least one hundred thousand but less than five hundred thousand, the board may operate a mental health service or facility under the following conditions:

(1) There is no other qualified private or public agency that is immediately available and willing to operate such service or facility.

(2) It is not feasible for the department of mental health to operate the facility or provide the service.

(3) Approval of the director shall be sought and obtained prior to the board undertaking the operation of the service or facility. The request for approval shall include:

(a) Evidence that there is no other agency qualified, available, and willing to provide the service or facility. This shall include a demonstration that all existing agencies have been reviewed in regard to qualifications, availability, and willingness.

(b) The operating plan for board provision of the service or facility.

(c) An operating plan demonstrating the ability of the board to continue to fulfill its mandated tasks and responsibilities as specified in section 340.03 of the Revised Code.

(d) A plan for ensuring that another agency will assume responsibility for operating the service or facility within one year.

(4) The service or facility may be operated by the board for no longer than one year.

(G) In any service district with a population of less than one hundred thousand, the board may operate a mental health service, or facility under the following conditions:

(1) The board operation of the service or facility must result in both greater administrative efficiency and more or better services than would be available if the board contracted with a private or public facility or community mental health agency.

(2) It is not feasible for the department of mental health to operate the facility or provide the service.

(3) Approval of the director shall be sought and obtained prior to the board undertaking the operation of the service or facility. The request for approval shall include the information in (G)(4)(b) of this rule.

(4) A board may operate a service or facility for no more than a year unless approved by:

(a) The board of county commissioners in a single county district or the approval of the majority of boards of county commissioners in a joint-county district; and

(b) The director. The request for approval of the director shall contain the following:

(i) Evidence that board operation of the service or facility is consistent with and aids in achieving objectives as stated in the annual comprehensive community mental health plan required by section 340.03 of the Revised Code,

(ii) Evidence that board operation of the service or facility achieves greater administrative efficiency in the provision of that service or facility,

(iii) Evidence that board operation of the service or facility improves the quality of services offered or increases the amount of services offered.

(iv) The operating plan for board provision of the service or facility.

(v) An operating plan demonstrating the ability of the board to continue to fulfill its mandated tasks and responsibilities as specified in section 340.03 of the Revised Code.

(H) The director shall not give a board approval to operate a facility previously operated by a person or other government entity unless the board has established to the director's satisfaction that the person or other government entity cannot effectively operate the facility or that the person or other government entity has requested the board to take over operation of the facility. The director shall not give a board approval to provide a community mental health service previously provided by a community mental health agency unless the board has established to the director's satisfaction that the agency cannot effectively provide the service or that the agency has requested the board take over providing the service.

(I) Nothing in this rule authorizes a board to administer or direct the daily operation of any contract agency or its facilities or services. An agency may contract with a board for agency administrative services or staff direction to be provided by the board under the direction of the agency board. Such contractual arrangements must be clearly described in the approved board comprehensive annual plan as required by section 340.03 of the Revised Code.

(J) Any board which operates a service or facility under the provisions of this rule shall comply with all requirements and standards as specified in rules of the department promulgated pursuant to Chapter 119. of the Revised Code which are applicable to contract agencies.

(K) The director shall notify the requesting board of approval or disapproval in writing within sixty days of department receipt of all required evidence, assurances, and plans as specified in paragraph (F), or (G) of this rule. If a board submits a request to operate a facility or mental health service in an emergency in accordance with paragraph (E) of this rule, the director shall notify the requesting board of approval or disapproval within fourteen days of department receipt of all required evidence, assurances and plans, or the director shall notify the requesting board of the date by which the department expects to issue a response. The time frame for response shall take into consideration the nature of the emergency and the projected date identified by the board to begin operation of services or a facility, and shall not exceed sixty day of receipt of all required evidence, assurances and plans as specified in paragraph (E) of this rule. The director shall periodically review and evaluate any board operation of a mental health service or facility.

Effective: 04/15/2012
R.C. 119.032 review dates: 12/30/2011 and 04/15/2017
Promulgated Under: 119.03
Statutory Authority: 340.03 , 5119.01 , 5119.61
Rule Amplifies: 340.03 , 5119.01 , 5119.61
Prior Effective Dates: 9/24/1984

5122:2-1-06 Mediation procedures for community mental health boards and contract agencies of those boards.

(A) The purpose of this rule shall be to establish mediation procedures for community mental health boards and contract agencies of those boards.

(B) The provisions of this rule shall be applicable to the division of mental health facilities and services, community mental health boards and contract agencies.

(C) The provisions of this rule shall be liberally construed to promote resolution of disputes between community mental health boards and contract agencies.

(D) Request for mediation

(1) If either a board or an agency with which it contracts for mental health services, programs, or facilities proposes not to renew the contract or proposes substantial changes in contract terms, the other party shall be given written notice at least one hundred twenty days before the expiration date of the contract.

(2) The party given such notice may request advisory mediation within thirty days after receipt of the written notice.

(3) Request for mediation shall be in writing addressed to the "Chief, Division of Mental Health Facilities and Services, Department of Mental Health, 30 E. Broad Street, Columbus, Ohio 43215."

(4) Requests shall include a copy of the contract or agreement between the parties and a brief statement of issues in dispute.

(5) The chief shall contact the other party to the dispute within seven calendar days of receipt of the request to determine whether that party agrees to mediate the dispute.

(6) Should one party not agree to mediation, the chief shall notify both parties accordingly. No further procedures are then required by this rule.

(E) Selection of a mediator

(1) After the requirements of paragraph (D) of this rule have been satisfied, the parties will attempt to select an impartial mediator by mutual agreement. In the event the parties cannot reach such an agreement, by joint letter they will request the chief to submit a panel of not more than five names of persons considered qualified to mediate disputes by the chief. Representatives of the parties shall strike names from the panel alternately until one name remains. That person shall serve as mediator.

(2) An employee of the department who agrees to serve as a mediator on a non-fee basis may be mutually selected by the parties.

(F) Function of mediator

(1) The sole function of the mediator shall be advisory in nature.

(2) The mediator shall have the authority to:

(a) Request documents or other material from either party in order to mediate the dispute;

(b) Submit written questions to either party;

(c) Conduct joint meeting between the parties;

(d) Make written recommendations to the parties for resolution of the dispute;

(e) Establish timelines for resolution of the dispute.

(G) Joint meeting

(1) The mediator shall arrange a meeting between the parties for the purpose of receiving arguments and written material concerning each party's position.

(2) Each party shall designate one representative, authorized to represent the party pending ratification by the appropriate board, to the meeting. The parties may send other personnel to the meeting in addition to the representative.

(3) Each party shall present arguments on the merits of their position and submit written material or exhibits relevant to a resolution of the dispute at the meeting, provided that the mediator may require presentation of written material to the other party and the mediator, prior to the meeting.

(4) The mediator shall preside at the meeting and at his discretion:

(a) Limit the length of each party's oral presentation;

(b) Limit the amount of written material or exhibits submitted by a party at a meeting;

(c) Decide whether material submitted is relevant to the issues in dispute and exclude material that is not relevant or cumulative;

(d) Provide for the meeting to be recorded, by tape recorder or other means;

(e) Adopt other procedures to govern the conduct of the meeting or necessary for equitable presentation of each party's position.

(5) The "Ohio Rules of Evidence" shall not apply to the proceeding between the parties at a joint meeting.

(6) At the conclusion of the joint meeting, the mediator shall set a date for issuance of his written recommendations for resolution of the dispute.

(H) Recommendations:

(1) The mediator shall make written recommendations for resolution of the dispute.

(2) A copy of the mediator's recommendations shall be sent to the chief of mental health facilities and services and the parties.

(3) The mediator's recommendations shall not be binding on either party.

(I) Time for completion of mediation

(1) The mediation shall be completed within sixty calendar days from the date of the request for mediation, unless both parties agree to a time extension.

(2) Neither party shall agree to extend the time for mediation for a period exceeding ten calendar days.

(3) An agreement to extend the time for mediation must be in writing, signed by a representative of both parties and contain a date for completion of the mediation.

(4) Agreements to extend the time for mediation must be submitted to the mediator within seven calendar days of the selection of the mediator.

(J) Mediation fees

(1) The fee, if any, of the mediator shall be divided equally between the parties.

(2) Each party shall otherwise be responsible for his own expenses arising from the utilization of the mediator.

Replaces: 5122:2-1-14

R.C. 119.032 review dates: 01/09/2004 and 01/09/2009

Promulgated Under: 119.03

Statutory Authority: 340.03(A)

Rule Amplifies: 340.03(A)

Prior Effective Dates: 5/1/68, 11/15/82

5122:2-1-09 [Rescinded] Community plan.

Effective: 02/17/2012
R.C. 119.032 review dates: 11/30/2011
Promulgated Under: 119.03
Statutory Authority: 5119.61
Rule Amplifies: 5119.61
Prior Effective Dates: 5/1/1968

5122:2-1-10 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.

(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.

(6) "Employee" means each Ohio department of mental health employee regardless of whether he/she 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 his/her 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 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 42 U.S.C. 45 C.F.R. parts160 to 164 (protected health information under the Health Insurance Portability and Accountability Act).

(3) 42 U.S.C. 9501 and 42 U.S.C. § 10841 (patient records).

(4) 42 C.F.R. 482.13 (patient records).

(5) Sections 2305.24 , 2305.25 , 2305.251 , 2305.252 , 2305.253 and 5122.32 of the Revised Code (quality assurance and peer review records).

(6) Section 5122.31 of the Revised Code (patient certificates, applications, records, and reports).

(7) Section 5122.311 of the Revised Code (notification of bureau of criminal identification and investigation of adjudication of mental illness).

(8) Paragraph (D)(13) of rule 5122:2-1-02 of the Administrative Code(client communications and personally identifying information).

(9) 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).

(10) Paragraph (C)(3) of rule 5122-2-25 of the Administrative Code(morbidity, mortality, and sentinel events).

(11) Paragraph (D)(5)(g) of rule 5122-3-13 of the Administrative Code(incident reports).

(12) Paragraph (A)(9)(11) of rule 5122-26-07 of the Administrative Code(personnel records of certified community mental health agencies).

(13) Paragraph (B)(11) 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 that 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

Effective: 09/09/2010
R.C. 119.032 review dates: 09/09/2015
Promulgated Under: 119.03
Statutory Authority: 1347.15 , 5119.01
Rule Amplifies: 1347.01 , 1347.05 , 1347.15 , 5119.01

5122:2-1-15 Civil rights. [Rescinded].

Rescinded eff 3-25-04