Report 2016-046 Recommendation 11 Responses

Report 2016-046: Board of Registered Nursing: Significant Delays and Inadequate Oversight of the Complaint Resolution Process Have Allowed Some Nurses Who May Pose a Risk to Patient Safety to Continue Practicing (Release Date: December 2016)

Recommendation #11 To: Registered Nursing, Board of

To ensure it does not risk compromising private and confidential information related to ongoing investigations of complaints, BRN should immediately ensure that any email correspondence it has with expert witnesses is transmitted securely.

Annual Follow-Up Agency Response From October 2018

The BRN ensures any email correspondence it has with expert witnesses is transmitted securely to ensure it does not risk compromising private and confidential information related to ongoing investigations of complaints.

  • Completion Date: December 2016

California State Auditor's Assessment of Annual Follow-Up Status: Partially Implemented

Although BRN developed procedures for instructing staff on how to send the investigative report and case materials to the expert witness, the procedures do not specify that staff should ensure that any correspondence or documents it sends to expert witnesses is transmitted securely, or that sensitive information is redacted. Thus, until it establishes this as part of its official policy, we will report this as partially implemented.

  • Auditee did not substantiate its claim of full implementation

1-Year Agency Response

The BRN ensures any email correspondence it has with expert witnesses is transmitted securely to ensure it does not risk compromising private and confidential information related to ongoing investigations of complaints.

  • Completion Date: December 2016
  • Response Date: June 2018

California State Auditor's Assessment of 1-Year Status: Pending

Although BRN claims it has fully implemented this recommendation, it did not provide evidence demonstrating that it has. Until it does so, we will continue to assess the status of this recommendation as pending.

  • Auditee did not substantiate its claim of full implementation

6-Month Agency Response

As of November 21, 2016, the BRN began omitting any subject RN's name from e-mails sent to the experts, as was specified in the auditor's recommendation.

Instruction was included in the Complaint Intake policies and procedures manual prohibiting the transfer of personally identifiable information via e-mail.

BRN will pursue an electronic transfer of materials via the secure DCA Cloud to further this recommendation. The BRN is also exploring best practices with other healing arts boards and the Attorney General's Office (AGO) regarding this process.

  • Completion Date: December 2016
  • Response Date: June 2017

California State Auditor's Assessment of 6-Month Status: Pending

BRN did not provide documentation to substantiate its claim of full implementation.

  • Auditee did not substantiate its claim of full implementation

60-Day Agency Response

To ensure e-mail correspondence with expert witnesses are transmitted in a secure environment, personally identifiable information related to investigation of complaints is no longer be transmitted in e-mails. Hence, case review material is being sent via the U.S. Postal Mailing system. This process has been updated in the Complaint Intake Policies and Procedures manual.

  • Completion Date: December 2016
  • Response Date: February 2017

California State Auditor's Assessment of 60-Day Status: Partially Implemented

Although BRN developed a policy for staff to send by traditional mail the investigative report and case materials to the expert witness rather than email, the policy does not specify that staff should ensure that any correspondence or documents it sends to expert witnesses is transmitted securely, or that sensitive information is redacted. Thus, until it establishes this as part of its official policy, we will report this as partially implemented.

  • Auditee did not substantiate its claim of full implementation

All Recommendations in 2016-046

Agency responses received are posted verbatim.