Report 2016-046 Recommendation 14 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 #14 To: Registered Nursing, Board of

To ensure that it is able to accurately monitor the performance of its complaint resolution process and that it has accurate data to address its staffing needs, BRN should develop and implement training for all BRN complaint processing staff that instructs them on how to accurately enter information in complaint records that are contained in BreEZe, including the date BRN received the complaint, in a manner that is consistent with BRN's business processes.

Annual Follow-Up Agency Response From October 2018

The BRN has developed and implemented training for all BRN complaint processing staff to ensure the BRN is able to accurately monitor the performance of its complaint resolution process and has accurate data to address its staffing needs. The training instructs staff how to accurately enter information in complaint records that are contained in BreEZe, including the date BRN received the complaint, in a manner consistent with BRN's business processes.

  • Completion Date: March 2017

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

The BRN provided training to staff instructing them on how to accurately enter information in complaint records that are contained in BreEZe. Further, it included procedures in its desk manual for staff to follow when entering information in complaint records that are contained in BreEZe.


1-Year Agency Response

The BRN has developed and implemented training for all BRN complaint processing staff to ensure the BRN is able to accurately monitor the performance of its complaint resolution process and has accurate data to address its staffing needs. The training instructs staff how to accurately enter information in complaint records that are contained in BreEZe, including the date BRN received the complaint, in a manner consistent with BRN's business processes.

  • Completion Date: March 2017
  • 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

On February 24, 2017, all BRN Complaint Intake staff completed training on BreEZe input coding. This training ensures unit practice is consistent with the BRN business process and data collection needs.

The training curriculum is saved for future training of new staff or refresher training should it be necessary. All staff completed sign-in sheets for the training.

Training material was incorporated into the Complaint Intake Unit procedure manual for complaint and Consumer Protection Enforcement Initiative (CPEI) guideline evaluation and referral (see pages 77-78). Staff instructions for accurately inputting complaint receipt dates are located on pages 17, 40, 42, and 59 of the Complaint Intake Unit procedure manual.

  • Completion Date: March 2017
  • 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

In order to ensure accurate monitoring of performance of the complaint resolution processes, all BRN complaint processing staff members have attended the SOLID BreEZe Basics for Enforcement. Proof of training completion is tracked in the BRN centralized training tracking system. All future new staff will also be required to attend this training.

Additionally, monitoring of staff performance is highlighted in the aforementioned detailed data reports. Manager review of the available data reports will identify issues such as coding errors and process delays.

All policies and procedures have been updated to include the specific BreEZe coding requirements for the complaint resolution process which is consistent with BRN's business processes.

  • Completion Date: January 2017
  • Response Date: February 2017

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

Although BRN provided evidence of an Outlook calendar appointment for a mandatory BreEZe coding training, it did not provide evidence demonstrating that it provided the training to all BRN complaint processing staff and that the training instructed the staff on how to accurately enter information in complaint records that are contained in BreEZe, including the date BRN received the complaint, in a manner that is consistent with BRN's business processes.

  • Auditee did not substantiate its claim of full implementation

All Recommendations in 2016-046

Agency responses received are posted verbatim.