5.1 Personally Identifiable Information (PII)
- 5.1.1 The CFC shall ensure the confidentiality of all PII collected or maintained pursuant to Part C Regulations, in accordance with the FERPA, 20 U.S.C. 1232 (g) and 34 CFR part 99 and 89 Illinois Administrative Code 500.
- 5.1.2 The confidentiality procedures described in this policy apply to PII of a child and the child's family that is contained in EI records collected, used or maintained under Part C Regulations from the point in time when the child is referred for EI services until records are no longer required to be maintained under applicable Federal and State law. (See 5.10-Retention of Record, later in this Chapter)
- 5.1.3 PII is defined as:
- the child's name;
- the name of the child's parent or other family members;
- the address of the child or the child's family;
- personal identifiers, such as the child's social security number;
- other identifiers, such as the child's date of birth, place of birth, mother's maiden name;
- other information, that alone or in combination is linkable to a specific child that would allow a reasonable person to identify the child; or
- information requested by a person who the provider believes knows the identity of the child to whom the EI record relates.
- 5.1.4 Each CFC must protect the confidentiality of PII at the collection, maintenance, use, storage, disclosure and destruction stages.
- 5.2.1 One official at each CFC shall be designated the Confidentiality Officer. The Confidentiality Officer shall assume responsibility for ensuring the confidentiality of any PII.
- 5.2.2 All persons collecting or using PII must receive training or instruction regarding the State's policies and procedures and participation in this training shall be documented in each individual's personnel file.
- 5.2.3 Each CFC must maintain, for public inspection, a current list of those employees within the agency who may have access to PII. The list shall detail the specific type of information each person has access to and be kept current.
- 5.2.4 The CFC must keep a record of parties obtaining access to EI records (except access by parents and authorized representatives and employees) including: (1) the name of the party; (2) the date access was given; and (3) the purpose for which the party is authorized to access the EI records.
5.3 EI Records - Paper Records
- 5.3.1 CFCs shall maintain a permanent case record for each child served by the CFC. This record shall be separate from clinical records if the agency also provides treatment or therapy.
- 5.3.2 Permanent open case records shall be housed at the main CFC office.
- 5.3.3 A working file may be copied for use in each satellite office and in the field. Archived files must be accessible for monitoring purposes.
- 5.3.4 All entries to records shall be kept current. Entries must be legible, dated and the author designated. If the record is a hard copy, the author shall sign and date the entry.
- 5.3.5 All paper records shall be secured with a locking mechanism. Only authorized personnel shall have access to such records.
- 5.3.6 A CFC may convert a file from paper storage to electronic storage utilizing the following criteria:
- The record is converted following HIPAA and FERPA regulations;
- The CFC maintains a second and separate location of a backup copy of the electronic record for the required timeframe matching paper records, and
- The CFC must still follow all other Record Retention policy and procedures as listed in this Chapter.
5.4 EI Records - Electronic Format
- 5.4.1 One official at each CFC shall be designated the Security Officer. Each CFC is responsible for implementation of HIPAA Security requirements to EI records in electronic format.
- 5.4.2 When PII is transmitted between the CFC and the EI Program in electronic format, the preferred method of communication is via the CBO Secure webmail system. If the CBO Secure webmail system cannot be used, the CFC shall: (1) encrypt and password protect the information; or (2) fax via a stand-alone fax (transmission via telephone line) with a cover letter with appropriate privacy notifications included.
- 5.4.3 When PII is transmitted between the providers and the CFC in electronic format, the sender shall:
- Encrypt and password protect the information; or
- Fax via a stand-alone fax (transmission via telephone line) with a cover letter with appropriate privacy notifications included. All fax transmissions should be conducted using stand-alone fax systems.
- Services not allowed: Online Voice over Internet Protocol (VoIP) E-Fax services are not compliant with HIPAA or FERPA requirements and should not be used for transmission of information from providers or CFCs.
- 5.4.4 Email communications between a parent or any other individual designated by the parent and the CFC shall be encrypted and password protected unless the parent has given written consent to allow communication via a public internet system. The consent must name the entity or entities that will be allowed to receive and respond to non-secure email communications. This consent must be kept in the child's permanent CFC record.
- 5.4.5 Personal laptops and tablet/e-reader devices cannot be used. Personal smart phones, PDA devices, and digital cameras without secured media (including but not limited to I-Phones, Droids, and Blackberries) cannot be used to take pictures or transmit information containing PHI.
5.5 Departure of CFC Employee
- 5.5.1 If a person leaves the employment of the CFC, the CFC shall take the following steps within three calendar days of that person's last date of employment: (1) transfer all active cases (if applicable) to a new Service Coordinator and shut down the Cornerstone user ID; and (2) if the person is credentialed, notify Provider Connections via fax or e-mail of the persons last date of employment with the CFC.
5.6 Confidentiality Notice for Parents
5.6.1 The CFC shall give parents the CFC Notice of Confidentiality Practices when a child is referred for Part C services. The notice shall include:
- a description of the child on whom PII is maintained;
- the type of information sought;
- the methods the State intends to use in gathering the information;
- the sources from whom the information is gathered;
- the uses of the information;
- a summary of the policies and procedures the CFC and providers must follow regarding storage, disclosure to third parties, retention and destruction of PII;
- a description of the rights of parents and children regarding the PII; and
- a description of the extent that the notice is provided in native languages in the various population groups in the State.
5.7 Parents Access to EI Records
- 5.7.1 The CFC shall comply with a parent's request to inspect and review any EI records, including records related to evaluations/ assessments, screening, eligibility determinations, development and implementation of IFSPs, provision of EI services, individual complaints involving the child, or any part of the child's EI record.
- 5.7.2 The CFC must reply with a request without unnecessary delay, and before any meeting regarding an IFSP and before any Due Process Hearing. In all cases, the CFC shall comply within 10 calendar days after the request has been made.
- 5.7.3 The right to inspect and review includes, the right to:
- A response from the CFC to reasonable requests for explanations and interpretations of the EI records;
- Request copies; and
- Have a representative of the parent inspect and review the EI records.
- 5.7.4 The parents shall be provided at no cost, a copy of each Evaluation/Assessment of the child, family assessment and IFSP as soon as possible after each IFSP meeting.
- 5.7.5 The CFC may charge a fee for copies of records that are made for parents if the fee does not effectively prevent the parents from exercising their right to inspect and review the records. The CFC may not charge a search fee to retrieve information.
- 5.7.6 The CFC may presume that the parent has authority to inspect and review records relating to his or her child unless the agency has been provided documentation that the parent does not have the legal authority.
- 5.7.7 If an EI record includes information on more than one child, the parents of those children only have the right to inspect and review the information relating to their child or to be informed of that specific information.
- 5.7.8 Upon request, the CFC must provide parents a list of the types and locations of EI records collected, maintained, or used.
5.8 Amendment of Records at Parent's Request
- 5.8.1 A parent who believes that information in their child's EI records are inaccurate, misleading or violates the privacy or other rights of the child or parent may request that the CFC amend the information. The CFC must decide whether to amend the information within five (5) business days of the request.
- 5.8.2 If the CFC denies the request to amend the records, the CFC must:
- Inform the parent;
- Advise the parent of a right to an informal hearing; and
- Notify the Bureau of EI within the five (5) business-day time period referenced above.
- The Bureau of EI will set the informal hearing within seven (7) business days of receiving notice of the dispute. The hearing officer will be designated by the Part C Coordinator. The parent shall be given the opportunity to present evidence and may at his or her own expense, be assisted or represented by one or more individuals, including an attorney. A decision will be issued in writing within ten (10) business days of the completion of the hearing. The decision must be based solely on the evidence presented at the hearing, and must include a summary of the evidence and the reasons for the decisions.
- 5.8.3 If the outcome of the hearing is that the record must be amended, the information shall be amended and the parent shall be informed in writing. If the outcome of the hearing is the record does not need to be amended, the parent must be notified that he or she has a right to place in the EI record a statement commenting on the information and setting forth any reasons for disagreeing with the decision. The statement must be maintained as part of the EI permanent record as long as the record is maintained by the CFC and if the records are disclosed to any party the statement also shall be disclosed to the party.
5.9 Parental Consent Prior to Disclosure of EI Records to Third Party
- 5.9.1 The CFC shall handle 3rd party requests for documents maintained by the CFC in the course of providing EI services. Any disclosure of PII to a third party shall be in compliance with 34 CFR Part 303.414.
- 5.9.2 If the request relates to records maintained by the DHS- Bureau of EI or the CBO, the CFC shall instruct the requestor to contact DHS or the CBO directly.
5.10 Retention of Records
Records shall be maintained for a period of at least six years from the child's discharge from EI, unless legal action is pending. If legal action is pending, the records shall be maintained in compliance with instructions from the Part C Coordinator.
5.11 Destruction of Records
- 5.11.1 At intake, the CFC shall inform the parent that paper records must be maintained for six years after the child stops receiving Part C services. If the parent would like the records destroyed after the child turns three, the CFC shall destroy the records. This means physical destruction of the paper record or ensuring all personal identifiers are removed from the record so that the record is no longer personally identifiable.
- However, a permanent record of a child's name, date of birth, parent contact information (including address and phone number), names of Service Coordinator(s) and provider(s), exit data (including year and age upon exit, and any programs entered into upon exiting) may be maintained without time limitation in Cornerstone. The paper records shall not be destroyed if litigation is threatened or pending without written permission from the Part C Coordinator.
- 5.11.2 All removable media, including floppy disks, CDs, DVDs, cassettes and flash drives that contain PII shall be destroyed or sanitized prior to being discarded.
5.12 Lost or Stolen Records
- 5.12.1 Facilities for the handling, processing and storage of records (whether hard copy, magnetic tapes, computer files or other automated systems, etc.) shall be secured from unauthorized access, theft, loss, fire or other natural occurrences.
- 5.12.2 The CFC shall immediately notify the Part C Coordinator of the DHS EI Program in writing upon discovery of any lost or stolen PII stored on any device that holds digital information (e.g. laptop, flash drive, floppy disks.)
Parents may file a State Complaint for violations of any of these procedural safeguards, unless a different remedy is specifically stated. DHS may impose appropriate sanctions for such violations.
5.14 CFC Permanent Case Records
All case records shall contain at a minimum:
- Accurate demographic, referral, financial and Insurance/All Kids information.
- Signed releases and consents;
- Evaluation/Assessment reports, including copies of any reports that have been translated into a family's native language, and documentation of initial and annual eligibility determination;
- Current and past IFSPs;
- Service coordination case notes unless maintained electronically.
NOTE: Case notes must contain accurate documentation and must include a summary of all conversations held between a Service Coordinator and a child's family and/or providers. If the incident was not case noted, the incident did not occur. Service Coordinator documentation must corroborate a service provider's consultation between the service provider and the Service Coordinator;
- Any other periodic reviews describing the child's overall progress;
- Signed Screening Device for Determining Family Fees and Eligibility for All Kids & DSCC (DSCC Screening Device) which is completed at intake and annual eligibility determinations and the Illinois Division of Specialized Care for Children (DSCC) documentation of eligibility or ineligibility for All Kids and DSCC, if applicable;
- A copy of the initial voluntary family assessment completed by the Service Coordinator at Intake and a written summary in a DHS-specified format that summarizes the results of that assessment, including a family's issues, priorities and concerns;
- Copies of all correspondence between CFC staff and the child's family, physician, EI service providers and anyone else contacted regarding the child, including copies of any correspondence that has been translated into a family's native language;
- PII disclosure log;
- If closed, a case closure summary documenting the IFSP functional outcomes, the child's current EI levels of development, the child's exit outcomes ratings, and a new hard copy of the service coordination case notes, and
- Any other information required per policy, rule or law.
5.15 CFC Permanent Case Record Outline
CFC Permanent Case Records are arranged in sections with dividers. As documents are updated, file them in reverse chronological order so the most current document is on top. If a CFC selects a similar outline that does not exactly match the recommended outline below, the CFC must have a Permanent Case Record listing showing the sections and documents included to allow monitors, auditors and others to easily find the required documentation. Hard copy items shall be filed as follows, if applicable, for the child and family:
Section 1- Referral/Intake/Legal
- Consents (hard copy required)
- Releases (hard copy required)
- EI - ISBE Surrogate Parent Request Form
- Guardianship Information
- Other intake documentation (i.e., participant's medical information, referral and social security disclosure form)
- Routines Based Interview (RBI)
- Provider choice form(s)
- Other legal status information
Section 2 - Service Plans
- EI - Authorizations and attachments (hard copy required)
- EI - Interim IFSP and attachments (hard copy required)
- EI - IFSP and attachments (hard copy required)
- EI Developmental Justifications to change an IFSP
- Early Intervention to Early Childhood Tracking form
- Copies of CFC Provisional Provider Authorization Requests and corresponding decision memos from DHS, if applicable
Section 3 - Reports
- EI Reports, including but not limited to Evaluation/Assessment reports, including: initial, 6-month or annual, discharge, including copies of reports translated into a family's native language (hard copy required)
- Medical Reports (Health Summary Forms, Immunization Records, Other Medical Reports)
- Completed voluntary family assessment and summary of assessment
- Ages & Stages Questionnaire: Social Emotional (ASQ:SE)
- Assistive Technology (AT) requests and related documentation
- Physician scripts and other medical authorizations
- All other documentation collected during eligibility determination or IFSP development, monitoring and update process (i.e., previous outside screenings, assessments, evaluations, etc.)
Section 4 - Correspondence
* Letters, memos, e-mails (except insurance correspondence which is filed in the Financial Section), including letters and memos translated into a family's native language (hard copy required)
Section 5 - Financial
- Financial assessment/documentation of income (hard copy required)
- Family Participation Fee exemption request(s), Family Fee credit requests and attachments, if applicable (hard copy required)
- Public benefits/private insurance consent(s) (hard copy required)
- Documentation of private insurance coverage and waivers
- Insurance exemption request and attachments, if applicable (hard copy required)
- Documentation of public benefits coverage, copy of All Kids recipient identification card or screen print of Cornerstone PA42, if applicable (hard copy required)
- Insurance correspondence
- Documentation regarding eligibility or ineligibility for other third party payors, including DSCC Screening Device (hard copy required)
Section 6 - PII Disclosure Log
- A PII disclosure log must be attached to the front inside cover of each file