In Touch Support Services

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Privacy And Confidentiality Policy And Procedure

Purpose and scope

This policy and procedure sets out staff responsibilities relating to collecting, using, protecting and releasing personal information, in compliance with privacy legislation.

It applies to all:
•    In Touch Support Services staff
•    aspects of In Touch Support Services operations
•    staff and participant personal information.

This policy and procedure should be read in conjunction with In Touch Support Services Records and Information Management Policy and Procedure. It meets relevant legislation, regulations and Standards

Applicable NDIS Practice Standards

Information Management

Outcome

Management of each participant’s information ensures that it is identifiable, accurately recorded, current and confidential. Each participant’s information is easily accessible to the participant and appropriately utilised by relevant workers.

Indicators

•    Each participant’s consent is obtained to collect, use and retain their information or to disclose their information (including assessments) to other parties, including details of the purpose of collection, use and disclosure. Each participant is informed in what circumstances the information could be disclosed, including that the information could be provided without their consent if required or authorised by law.

•    Each participant is informed of how their information is stored and used, and when and how each participant can access or correct their information and withdraw or amend their prior consent.

Privacy and Dignity

Outcome

Each participant accesses supports that respect and protect their dignity and right to privacy.

Indicators

•    Consistent processes and practices are in place that respect and protect the personal privacy and dignity of each participant.

•    Each participant is advised of confidentiality policies using the language, mode of communication and terms that the participant is most likely to understand.
 

•    Each participant understands and agrees to what personal information will be collected and why, including recorded material in audio and/or visual format.

Interaction of Applicable Legislation and Associated Definitions

Privacy Act 1988 (Cth) – regulates how personal information about individuals is handled. The Act includes thirteen Australian Privacy Principles (APPs). The APPs set out standards, rights and obligations for the handling, holding, use, accessing and correction of personal information. The Act protects the privacy of an individual’s information where it relates to Commonwealth agencies and private businesses (including not-for-profit organisations) with a turnover of more than $3 million. All organisations that provide a health service and hold health information (other than in a staff record) are covered by the Act.

Health Information – personal information or an opinion about:
•    the health, including an illness, disability or injury, (at any time) of an individual
•    an individual’s expressed wishes about the future provision of health services to the individual
•    a health service provided, or to be provided, to an individual that is also:


o    Personal Information
o    Other Personal Information collected to provide, or in providing, a health service to an individual
o    Other Personal Information collected in connection with the donation, or intended donation, by an individual of his or her body parts, organs or body substances
o    genetic information about an individual in a form that is, or could be, predictive of the health of the individual or a genetic relative of the individual.

Personal Information – information or an opinion about an identified individual, or an individual who is reasonably identifiable:


•    whether the information or opinion is true or not
•    whether the information or opinion is recorded in a material form or not

Sensitive Information – personal information or an opinion about an individual’s:
•    racial or ethnic origin
•    political opinions
•    membership of a political association
•    religious beliefs or affiliations
•    philosophical beliefs
•    membership of a professional or trade association
•    membership of a trade union
•    sexual orientation or practices
•    criminal record
 
that is also:
o    Personal Information
o    Health Information about an individual
o    genetic information about an individual that is not otherwise health information
o    biometric information that is to be used for the purpose of automated biometric verification or biometric identification
o    biometric templates.

National Disability Insurance Scheme Act 2013 (Cth) – regulates how personal information about NDIS participants is handled by the National Disability Insurance Agency. This limits how the Agency collects and uses personal information and when and to whom information can be disclosed. The Agency must also comply with the Privacy Act 1988 (Cth).

Protected Information – information:
•    about a person that is or was held in the records of the Agency; or
•    to the effect that there is no information about a person held in the records of the Agency.

Queensland    

Queensland has privacy legislation that applies only to its public sector, including public sector health service providers. The Information Privacy Act 2009 (Qld) regulates how personal information is handled by Queensland public sector agencies.

Health Information —
•    personal information about an individual that includes any of the following:
o    the individual’s health at any time
o    a disability of the individual at any time
o    the individual’s expressed wishes about the future provision of health services to the individual
o    a health service that has been provided, or will be provided, to the individual
•    personal information about the individual collected for the purpose of providing, or in providing, a health service
•    personal information about the individual collected in connection with the donation, or intended donation, by the individual of any of the individual’s body parts, organs or body substances

Personal Information – information or an opinion, including information or an opinion forming part of a database, whether true or not and recorded in a material form or not, about an individual whose identity is apparent, or can reasonably be ascertained, from the information or opinion.
 
Sensitive Information —
•    personal information about an individual that includes their:
o    racial or ethnic origin
o    political opinions
o    membership of a political association
o    religious beliefs or affiliations
o    philosophical beliefs
o    membership of a professional or trade association
o    membership of a trade union
o    sexual preferences or practices
o    criminal record
•    information that is health information about the individual.

Private sector service providers must comply with the Privacy Act 1988 (Cth) when handling health information.

The Queensland Office of the Information Commissioner receives and conciliates complaints related to the privacy of health information.

The Queensland Health Ombudsman can receive and investigate complaints about health services and health service providers, including registered and unregistered health practitioners.

Policy

In Touch Support Services recognises, respects and protects everyone’s right to privacy, including the privacy of its participants and staff. All individuals (or their legal representatives) have the right to decide who has access to their personal information.

In Touch Support Services privacy and confidentiality practices support and are supported by its records and information management processes (see the Records and Information Management Policy and Procedure.

Privacy and Confidentiality processes interact with the information lifecycle in the following ways:

Privacy Policy Image 1

All staff are responsible for maintaining the privacy and confidentiality of participants, other staff and In Touch Support Services.

Procedures

General

The Director is responsible for ensuring In Touch Support Services complies with the requirements of the Privacy Act 1988 (Cth). This includes developing, implementing and reviewing processes that address:


•    why and how In Touch Support Services collects, uses and discloses personal information
•    what information In Touch Support Services collects about individuals and its source;
•    who has access to the information
•    information collection, storage, access, use, disclosure and disposal risks
•    how individuals can consent to personal information being collected, withdraw or change their consent and change information about them held by In Touch Support Services
•    how In Touch Support Services safeguards and manages personal information, including how it manages privacy queries and complaints
•    how information that needs to be updated, destroyed or erased is managed

The Director reviews these processes regularly, through annual Privacy Audits (see In Touch Support Services Privacy Audit Form and Schedule 2. External Audit and Internal Review Schedule.

All staff are responsible for complying with this policy and procedure and their privacy, confidentiality and information management responsibilities. Staff must keep personal information about participants, other staff and other stakeholders confidential, in accordance with the confidentiality provisions in their employment or engagement contract.

As per In Touch Support Services Human Resources Policy and Procedure, all staff must undergo Induction, which includes training in privacy, confidentiality and information management. Staff knowledge and application of confidentiality, privacy and information management processes is monitored on a day-to-day basis and through annual Performance Reviews. Additional formal and on-the-job training is provided to staff where required.
In Touch Support Service’s Privacy Statement prominently displayed in In Touch Support Services premises and] included in In Touch Support Services Participant Handbook.
 

The Privacy Statement [or equivalent] and a full copy of this policy and procedure must be provided upon request.

Photos and Videos

Photos, videos and other recordings are a form of personal information. Staff must respect people’s choices about being photographed or videoed and ensure images of people are used appropriately. This includes being aware of cultural sensitivities and the need for some images to be treated with special care.

Information Collection and Consent

Participant Information Collection and Consent

In Touch Support Services will only request personal information that is necessary to:
•    assess a potential participant’s eligibility for a service
•    provide a safe and responsive service
•    monitor the services provided
•    fulfil government requirements for non-identifying and statistical information.

Personal client information that In Touch Support Services collects includes, but is not limited to:

 
•    contact details for participants and their representatives or family members
•    details for emergency contacts and people authorised to act on behalf participants
•    participants’ health status and medical records
•    medication records
•    service delivery intake, assessment, monitoring and review information
•    assessments, reviews and service delivery records
•    external agency information
•    feedback and complaints
•    incident reports
•    consent forms
 

Prior to collecting personal information from participants or their representatives, staff must explain:
•    that In Touch Support Services only collects personal information that is necessary for safe and effective service delivery
•    that personal information is only used for the purpose it is collected and is stored securely
•    what information is required
•    why the information is being collected and how it will be stored and used
•    the occasions when the information may need to be shared and who or where the information may be disclosed to
•    the participant’s right to decline providing information
•    the participant’s rights in terms of providing, accessing, updating and using personal information, and giving and withdrawing their consent
•    the consequences (if any) if all or part of the information required is not provided.
 
Participants and their families must be provided with In Touch Support Services Privacy Statement and informed that a copy of this policy and procedure is available on request.

Staff must provide privacy information to participants and their families in ways that suit their individual communication needs. Written information can be explained verbally by staff. Staff can also help participants access interpreters or advocates where required.

After providing the above information, staff must use a Consent Form to:
•    confirm the above information has been provided and explained
•    obtain consent from participants or their legal representatives to collect, store, access, use, disclose and dispose of their personal information.

Participants and their representatives or families are responsible for:
•    providing accurate information when requested
•    completing Consent Forms and returning them in a timely manner
•    being sensitive and respectful to other people who do not want to be photographed or videoed
•    being sensitive and respectful of the privacy of other people in photographs and videos when using and disposing of them.


NDIS Audits

In Touch Support Services complies with the requirements of the National Disability Insurance Scheme (Approved Quality Auditors Scheme) Guidelines 2018 whereby participants are automatically included in audits against the NDIS Practice Standards. Participants may be contacted at any time by an NDIS Approved Quality Auditor for an interview, or for their participant file and plans to be reviewed.

Participants who do not wish to participate in these processes can notify any staff member, who must inform the Director in writing. Their decision will be respected by In Touch Support Services and will be documented in their participant file. Upon commencement of any audit process, In Touch Support Services notifies its Approved Quality Auditor of participants who have opted-out of the audit process.
 
Staff Information Collection and Consent

Personal staff information that In Touch Support Services collects includes, but is not limited to:

 
•    tax declaration forms
•    superannuation details
•    payroll details
•    employment / engagement contracts
•    personal details
•    emergency contact details
•    medical details
 
•    NDIS Worker Screening Checks, Police Checks and Working with Children Checks
•    qualifications
•    First Aid, CPR, Anaphylaxis and other relevant certificates
•    personal resumes
 

Where relevant, forms used to collect the above information will also obtain the staff member’s consent to collect, store, access, use, disclose and dispose of their personal information.

Storage

Refer to the Records and Information Management Policy and Procedure for details on how In Touch Support Services securely stores and protects staff and participant personal information.

Access

Staff personal information must only be accessed the Director, who may only access the information if it is required in order to perform their duties.

Staff must only access participants’ personal information if it is required in order to perform their duties.

Staff and participants have the right to:
•    request access to personal information In Touch Support Services holds about them, without providing a reason for requesting access
•    access this information
•    make corrections if they believe the information is not accurate, complete or up to date

All participant access or correction requests must be directed to a relevant staff member responsible for the maintenance of the participant’s personal information. All staff access or correction requests must be directed to the Director. Within [2 working days] of receiving an access or correction request, the responding staff member will:
•    provide access, or explain the reasons for access being denied
•    correct the personal information, or provide reasons for not correcting it
•    provide reasons for any anticipated delay in responding to the request

An access or correction request may be denied in part or in whole where:
•    the request is frivolous or vexatious
•    it would have an unreasonable impact on the privacy of other individuals
•    it would pose a serious threat to the life or health of any person
•    it would prejudice any investigations being undertaken by In Touch Support Services or any investigations it may be the subject of.
 

Any participant access or correction requests that are denied must be approved by the Director and documented on the participant’s file.

Any staff access or correction requests that are denied must be approved by the Director and documented on the staff member’s file.

Disclosure

Participant or staff personal information may only be disclosed:
•    for emergency medical treatment
•    to outside agencies with the person’s [or for child participants, parent or guardians’] permission
•    with written consent from someone with lawful authority
•    when required by law, or to fulfil legislative obligations such as mandatory reporting.

If a staff member is in a situation where they believe that they need to disclose information about a participant or other staff member that they ordinarily would not disclose, they must consult the Director before making the disclosure.


Reporting

Notifiable Data Breaches Scheme

Notifiable Data Breaches

A Notifiable Data Breach, also called an ‘eligible data breach’, occurs when:
there is unauthorised access to or disclosure of personal information, or information is lost in circumstances where unauthorised access or disclosure is likely to occur
the disclosure or loss is likely to result in serious harm to any of the people that the information relates to. In the context of a data breach, serious harm may include serious physical, psychological, emotional, financial, or reputational harm and
In Touch Support Services has been unable to prevent the likely risk of serious harm through remedial action.

If In Touch Support Services acts quickly to remediate a data breach and as a result it is not likely to result in serious harm, it is not considered a Notifiable Data Breach.

Detecting Data Breaches

Examples of data breaches include:
loss or theft of devices (such as phones, laptops, and storage devices) or paper records that contain personal information
unauthorised access to personal information by a staff member, for instance, a staff member browsing sensitive participant records without a legitimate purpose or a computer network being compromised by an external attacker resulting in personal information being accessed without authority
unauthorised disclosure of personal information due to ‘human error’, for example an email sent to the wrong person and disclosure of an individual’s personal information to a scammer, because of inadequate identity verification procedures.

In reality, and particularly with respect to electronic data, data breaches can be difficult to detect. As such, all staff are responsible for:
adhering to all In Touch Support Services Policies, Procedures and processes relating to data creation, storage, use, archiving and disposal
only transporting hard copy files and electronic storage devices in a secure, lockable container and with approval from the In Touch Support Services
implementing password protection and two-factor or multi-factor authentication on devices and software used to access In Touch Support Services information ensuring all operating systems, browsers and plugins used on devices to access In Touch Support Services information are up to date with patches and fixes and have appropriate security maintenance software installed and active and completely shutting down devices used to access In Touch Support Services information at least once a week, to ensure updates are installed.

The director is responsible for ensuring that:
security maintenance software is installed on all In Touch Support Services computers, to detect breaches as well as any peculiar activity all operating systems, browsers and plugins used on In Touch Support Services devices are up to date with patches and fixes software systems used by staff lock users out after multiple failed login attempts they are listed as a key contact person for notification from third party software providers in the event those systems are breached and they are subscribed to a data breach notification service so they are kept abreast of possible data breaches that could impact In Touch Support Services.

The director is responsible for ensuring that:
annual Privacy Audits are undertaken in accordance with the Internal Review and External Audit Schedule [or equivalent] and
all staff are adequately and regularly trained in all In Touch Support Services Policies, Procedures and processes relating to data creation, storage, use, archiving and disposal.


Password Management All staff must:
regularly reset their passwords
use passwords of at least 8 characters that include letters, numbers, and symbols if credentials have been compromised, reset passwords as soon as possible refrain from reusing the same password across critical services such as banking and social media sites or sharing passwords for a critical service with a non-critical service and ensure new passwords do not follow a recognisable pattern. Reporting a Data Breach All staff must report all potential or actual data breaches (including unusual activity in electronic systems and loss or theft of files or storage devices) as soon as possible to the Privacy Officer, who will determine In Touch Support Services’s response and whether the breach needs to be reported under the NDB Scheme.
 
If In Touch Support Services acts quickly to remediate a data breach and as a result it is not likely to result in serious harm, it is not considered a Notifiable Data Breach.


Responding to a Data Breach

If the Director suspects that a data breach is notifiable under the NDB Scheme, they must make an assessment to determine if this is the case.


•    The Director as Team Leader, responsible for leading the response team.
•    The Director as Project Manager, to coordinate the team and provide support to its members
•    The Director as legal support, to identify legal obligations and provide advice
•    The Director as risk management support, to assess the risks from the breach
•    The Director as Information and Communication Technology (ICT) or forensics support, to help establish the cause and impact of a data breach that involves ICT systems
•    The Director to provide information and records management expertise, assist in reviewing security and monitoring controls related to the breach (for example, access, authentication, encryption, audit logs) and provide advice on recording the response to the data breach
•    The Director as Human Resources support, if the breach was due to the actions of a staff member
•    The Director to provide media/communications expertise and assist in communicating with affected individuals and dealing with the media and external stakeholders.

The Director must notify all impacted individuals of the breach as soon as is practicable.

All data breach incidents (whether notifiable or not) must be responded to in accordance with In Touch Support Services Data Breach Response Plan and recorded in In Touch Support Services Incident Register, with relevant actions tracked in its Continuous Improvement Register where appropriate.

Where a breach is referred to the Director, its response will be based on the following steps:
•    Step 1: Contain the data breach
•    Step 2: Assess the data breach and the associated risks
•    Step 3: Notify individuals and the Australian Information Commissioner
•    Step 4: Prevent future breaches

See In Touch Support Services Data Breach Response Plan for further detail.

Notifiable Data Breaches Involving More Than One Entity

The NDB Scheme recognises that personal information is often held jointly by more than one entity. For example, one entity may have physical possession of the information, while another has legal control or ownership of it.

Examples include:
•    where information is held by a cloud service provider
•    subcontracting or brokering arrangements
•    joint ventures

In these circumstances, an eligible data breach is considered the responsibility of both entities under the NDB Scheme. However, only one entity needs to take the steps required by the NDB Scheme and this should be the entity with the most direct relationship with the people affected by the data breach. Where obligations under the Scheme (such as assessment or notification) are not carried out, both entities will be in breach of the Scheme’s requirements.

Other Reporting Requirements

The Director must immediately notify the NDIS Commission and [list any relevant complaints body in ‘Interaction of Applicable Legislation and Associated Definitions’] if they become aware of a breach or possible breach of privacy legislation.

Data breaches may also trigger reporting obligations outside of the Privacy Act 1988, such as to:
In Touch Support Services’s financial services provider
•    police or other law enforcement bodies
•    the Australian Securities and Investments Commission (ASIC)
•    the Australian Prudential Regulation Authority (APRA)
•    the Australian Taxation Office (ATO)
•    the Australian Transaction Reports and Analysis Centre (AUSTRAC)
•    the Australian Cyber Security Centre (ACSC)
•    the Australian Digital Health Agency (ADHA)
•    Federal, State or Territory Government departments
•    professional associations and regulatory bodies
•    insurance providers

Archiving and Disposal

Refer to the Records and Information Management Policy and Procedure for details on how In Touch Support Services archives and disposes of participants’ personal information.

Supporting Documents

Documents relevant to this policy and procedure include:
•    Consent Form
•    Records and Information Management Policy and Procedure
•    Data Breach Response Plan
•    Continuous Improvement Plan
•    Participant Handbook
•    Privacy Statement
•    Privacy Audit Form
 

Monitoring and Review

This policy and procedure will be reviewed at least every two years by the Director. Reviews will incorporate staff, participant and other stakeholder feedback.

In Touch Support Services feedback collection mechanisms, such as staff and participant satisfaction surveys, will assess:
•    satisfaction with In Touch Support Service’s privacy and confidentiality processes;
•    whether stakeholders have received adequate information about privacy and confidentiality; and
•    the extent to which participants and their supporters feel their privacy and confidentiality has been protected.

Touch Support Service’s Continuous Improvement Plan will be used to record improvements identified and monitor the progress of their implementation. Where relevant, this information will be considered as part of In Touch Support Services service planning and delivery processes.

DOCUMENT CONTROL

Privacy Policy Revision History