(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
(B) For the purposes of administrative
rules promulgated in accordance with section 1347.15 of the Revised Code, the
following definitions apply:
when used in this rule as a noun means an instance of copying, viewing, or
"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.
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.
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
(5) "Department" means the Ohio department of mental
health and addiction services.
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.
contact" means contact with the information that is secondary or
tangential to the primary purpose of the activity that resulted in the
(8) "Individual" means a natural person or the natural
person's authorized representative, legal counsel, legal custodian, or
owner" means the individual appointed in accordance with division (A) of
section 1347.05 of the Revised Code to be directly responsible for a
means a natural person.
information" has the same meaning as defined in division (E) of section
1347.01 of the Revised Code.
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
means a methodical investigation into a subject.
means commonplace, regular, habitual, or ordinary.
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.
has the same meaning as defined by division (F) of section 1347.01 of the
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
(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
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
(a) Verify the identity of the individual by a method that
provides safeguards commensurate with the risk associated with the confidential
(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;
(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
(3) Notice of invalid
(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
"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
(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
(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
(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
(9) Licensure or
(10) Investigation or law
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
(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).
(3) 42 U.S.C. 9501 and 42
U.S.C. 10841 (patient records).
(4) 42 C.F.R. 482.13
(5) 42 C.F.R. Part 2
(confidentiality of alcohol and drug abuse patient records).
(6) 42 U.S.C. 1396a(a)
(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
(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 (D)(3) of
rule 5122-2-25 of the Administrative Code (morbidity and mortality
(13) Paragraph (D)(4)(e)
of rule 5122-3-13 of the Administrative Code (incident reports).
(F) Restricting and logging access to
confidential personal information in computerized personal information
For personal information systems that are
computer systems and contain confidential personal information, the department
shall do the following:
Access to confidential personal information
that is kept electronically shall require a password or other authentication
(2) Acquisition of a new
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
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
(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
(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
(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.
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
(6) Nothing in this rule
limits the department from requiring logging in any circumstance that it deems