Report 2016-046 Recommendation 26 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 #26 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 establish formal procedures, such as managers performing routine audits of complaint files, to monitor incoming complaints and final dispositions.

Annual Follow-Up Agency Response From October 2018

To ensure BRN is promptly and appropriately sending notifications to complainants as state law requires, the BRN has established formal procedures for managers to perform routine audits of complaint files and monitor incoming complaints and final dispositions.

  • Completion Date: March 2017

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

Although BRN developed high-level management monitoring procedures that include conducting regular audits and reviews of staff workload to ensure timely completion of complaint processing, these procedures do not specify how management will ensure staff promptly and appropriately send required notifications to complainants. In addition, BRN did not demonstrate evidence of reports it uses to monitor and verify that its staff send notifications as the law requires. Until it does so, we will continue to assess this recommendation as partially implemented.

  • Auditee did not substantiate its claim of full implementation

1-Year Agency Response

To ensure BRN is promptly and appropriately sending notifications to complainants as state law requires, the BRN has established formal procedures for managers to perform routine audits of complaint files and monitor incoming complaints and final dispositions.

  • 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

Complaint intake policies and procedures have been updated to include staff timeframe expectations. The management monitoring plan outlines the process for the manager to audit all staff within the unit on an ongoing and routine basis to ensure staff is appropriately managing workload and adhering to timeframe expectations.

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

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

BRN did not provide any evidence that it has established formal procedures, such as requiring managers to perform routine audits of complaint files, to monitor incoming complaints and final dispositions. Until it does so, we will continue to report this recommendation as not fully implemented.

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

60-Day Agency Response

In addition to the Alert function and Policy and Procedure updates included in item 25 above, BRN Complaint Intake has developed formal management monitoring procedures which require monthly audits of complaint files to monitor incoming complaints and final dispositions. Moreover, the management monitoring procedures also highlight the use of the new data reports to evaluate pending workload and evaluate whether cases are progressing throughout the enforcement process in accordance with established milestones.

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

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

Although BRN developed high-level management monitoring procedures, these procedures do not specify how management will monitor incoming complaints and final dispositions, such as by performing routine audits, to ensure it promptly and appropriately sends required notifications to complainants.

  • 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.