(2) A health care facility shall file with the Oregon Health Authority a protection of health information report no later than 120 days following the close of each fiscal year. The report may be in the form of a letter, must be signed by the chief executive officer of the facility and must:

(a) State the responsibility of the health care facility’s management to establish and maintain adequate safeguards and procedures for protecting the confidentiality of personally identifiable and protected health information that the facility retains in electronic and hard copy form;

(b) Contain an assurance that there is ongoing evaluation and monitoring of the effectiveness of the safeguards and procedures in protecting the confidentiality of personally identifiable and protected health information;

(c) Contain assurances that the signing officer has disclosed to the board of directors of the facility:

(A) All significant deficiencies in the design or operation of recordkeeping systems or controls that could adversely affect the facility’s ability to protect the confidentiality of personally identifiable and protected health information;

(B) Any breaches of the security of personally identifiable and protected health information, whether material or not, that involve management, staff or employees of the facility who have a significant role in the facility’s recordkeeping systems or controls; and

(C) All necessary steps that have been taken to address deficiencies in the design or operation of recordkeeping systems or controls and to resolve any material weaknesses identified by the facility; and

(d) Contain assurances that the signing officer has identified for the board any material weaknesses in the recordkeeping systems or controls.

(3) The authority may adopt all rules necessary to carry out the provisions of this section.

(4) The protection of health information report is confidential and not subject to disclosure under ORS 192.311 to 192.478. [2015 c.133 §4]