Report 2016-046 Recommendation 21 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 #21 To: Registered Nursing, Board of

BRN should immediately stop overriding fingerprint holds in BreEZe based solely on the fact that fingerprint data is present in BRN's legacy system and, for those cases where it believes it is necessary to override the system, BRN should receive its executive officer's approval to do so and document both the reason for the override and evidence of the executive officer's approval.

Annual Follow-Up Agency Response From October 2018

The BRN only overrides fingerprint holds in BreEZe if the Executive Officer has approved to do so and has documented the reason with evidence of the Executive Officer's approval.

  • Completion Date: March 2017

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

BRN developed a procedure for staff to follow that describes the steps to take in BreEZe to override a fingerprint hold. This procedure also describes those instances where it is necessary for staff to override the system, and how staff should document the reasons for the override and evidence of the executive officer's approval. BRN provided evidence of the executive officer's approval.


1-Year Agency Response

The BRN only overrides fingerprint holds in BreEZe if the executive officer has approved to do so and has documented the reason with evidence of the executive officer's approval.

  • 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

The BRN has developed and implemented a manual fingerprint renewal process in BreEZe, which requires the Executive Officer (EO) approval. The approval of each record is documented in the renewal transaction notes section of BreEZe as well as a BreEZe report identifying each record that has been authorized by the EO for approval.

LiveScan fingerprint forms are maintained and monitored for results by staff. Once fingerprint results are received, populated to BreEZe, and verified by staff, the LiveScan forms are destroyed via confidential shred.

A "Processing Fingerprint Holds" procedure was developed and disseminated to staff. Only specific staff is authorized to clear the fingerprint business rule.

  • Completion Date: March 2017
  • Response Date: June 2017

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

BRN did not provide any documentation to substantiate the statements it made regarding its claim of full implementation.

  • Auditee did not substantiate its claim of full implementation

60-Day Agency Response

The BRN has developed and implemented a fingerprint renewal process in BreEZe, which requires the Executive Officer (EO) approval. The process documents the reason to approve the license renewal transaction as well as signatory approval by the EO. The documentation is scanned and attached to the licensee's renewal transaction and maintained in the BreEZe system.

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

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

Although BRN developed a process for staff to follow describing the steps to take in BreEZe to override a fingerprint hold, the process does not direct staff to only override the system in those instances where it believes it is necessary, obtain the executive officer's approval, and document both the reasons for the override and evidence of the executive officer's approval.

  • Auditee did not address all aspects of the recommendation

All Recommendations in 2016-046

Agency responses received are posted verbatim.