Report 2016-046 Recommendation 25 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 #25 To: Registered Nursing, Board of

To ensure that it promptly and appropriately sends notifications to complainants as state law requires, by March 2017, BRN should develop desk procedures that describe the actions enforcement staff members should take when processing incoming complaints and when BRN reaches a final disposition on a case.

6-Month Agency Response

Alerts were created based on the original auditor recommendation and are working as expected. Complaint intake policies and procedures were updated and include timeframe expectations.

As a result of feedback from the auditor, the BRN suggested additional changes to the Alerts, including the following:

- Update acknowledgement alert to 7 days

- Update closure letter alert to 21 days

- BRN submitted a ticket based on the Auditor 60-day response which was deployed in BreEZe release 2.18 on May 24, 2017.

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

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

BRN established an alert in BreEZe to automatically alert staff before the due date to send an acknowledgement letter within 10 days after BRN has received a complaint and a final disposition letter within 30 days after it has resolved a complaint. This alert will help ensure that BRN sends required notifications promptly. Additionally, BRN has developed procedures that describe the actions enforcement staff should take when processing incoming complaints and when BRN reaches a final disposition on a case.


60-Day Agency Response

The BRN SMEs worked with DCA's BIA to develop an Alert function within BreEZe if a complaint acknowledgement letter has not been created and sent within 10 days of a complaint being received by the BRN. Additionally, a second Alert has been created to notify when a closure letter has not been created within 30 days of the case closure date. These Alerts are ready to be deployed in the next BreEZe software release at the end of February 2017.

The Complaint Intake Policies and Procedures desk manuals have been updated to include complaint received acknowledgement and notification of closure timeframe requirements.

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

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

BRN established an alert in BreEZe to notify staff that they had not yet created an acknowledgement letter 10 days after BRN has received a complaint and when it has not sent a final disposition letter 30 days after it has resolved a complaint. However, because it established the alert to notify staff after it has already passed the deadline set by State Law for acknowledging receipt of a complaint, this alert will not ensure that it sends required notifications within the 10-day time frame specified in state law. Further, BRN has not developed procedures that describe the actions enforcement staff should take when processing incoming complaints and when BRN reaches a final disposition on a case.

  • Auditee did not substantiate its claim of full implementation
  • Auditee did not address all aspects of the recommendation

All Recommendations in 2016-046

Agency responses received are posted verbatim.