Report 2016-046 All Recommendation 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 for Legislative Action

To ensure that BRN receives timely and consistent notification of nurses' alleged violations of the Nursing Act, the Legislature should require the employers of registered nurses to report to BRN the suspension, termination, or resignation of any registered nurse due to alleged violations of the Nursing Act.

Description of Legislative Action

Senate Bill 799 (Hill, Chapter 520, Statutes of 2017) authorizes BRN to investigate at its discretion complaints against registered nurses participating in the intervention program, and prohibits disciplinary action with regard to acts committed before or during participation in the intervention program, unless the registered nurse withdraws or is terminated from the intervention program.

  • Legislative Action Current As-of: October 2017

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


Recommendation for Legislative Action

If BRN does not develop and implement an action plan by March 1, 2017, to prioritize and resolve its deficiencies, as mentioned in the first recommendation to BRN, the Legislature should consider transferring BRN's enforcement responsibilities to Consumer Affairs.

Description of Legislative Action

Legislation has not been introduced to address this recommendation.

  • Legislative Action Current As-of: October 2017

California State Auditor's Assessment of 1-Year Status: No Action Taken


Recommendation for Legislative Action

The Legislature should amend state law to require BRN to conduct investigations of complaints alleging substance abuse or mental illness against nurses who choose to enter the intervention program.

Description of Legislative Action

Legislation has not been implemented to address this recommendation. However, it should be noted that Senate Bill 799 (Hill, Chapter 520, Statutes of 2017) requires the California Research Bureau to prepare and deliver a report to the Legislature by January 1, 2019, that evaluates to what extent employers voluntarily report disciplined nurses to the board and that offers options for consistent and reasonable reporting mechanisms.

  • Legislative Action Current As-of: October 2017

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


Recommendation #4 To: Registered Nursing, Board of

To ensure that it promptly addresses this report's findings, BRN should work with Consumer Affairs to develop an action plan by March 1, 2017, to prioritize and resolve the deficiencies we identified.

60-Day Agency Response

On or about December 12, 2016, the Board of Registered Nursing's (BRN) Executive management developed an action plan that documents and tracks each of the enforcement audit recommendations, BRN's initial response to each recommendation, timeline to implement recommendations, responsible parties, and outcome of implementation of recommendations. BRN staff collaborated with the Department of Consumer Affairs (DCA) executive management, DCA's SOLID Training Solutions, DCA's Division of Investigation (DOI) and the Attorney General's Office (AG) to develop solutions including policies and procedures and measurable outcomes to implement the recommendations. The action plan is reviewed and updated on a regular basis to ensure BRN meets the recommendation deadlines.

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

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

BRN, in collaboration with DCA, has created a plan that lists each of our 23 recommendations, including what it has done, or plans to do, to implement our recommendations. Although the plan does not specifically prioritize our recommendations, based on our follow-up with DCA and BRN officials, BRN is prioritizing its work on the recommendations by ensuring each are fully implemented by the completion dates included in our recommendations.


Recommendation #5 To: Registered Nursing, Board of

To ensure that BRN resolves complaints regarding nurses in a timely manner, by March 1, 2017, it should develop and implement formal policies that specify required time frames for each key stage of the complaint resolution process, including time frames for how quickly complaints should be assigned to the proper investigative unit or expert witness, and how long the investigation process should take. BRN should also work with DOI to establish a reasonable goal for the length of time DOI's investigators take to conduct investigations of complaints referred to it by BRN.

6-Month Agency Response

As of March 6, 2017, newly developed BreEZe reports are in full production. Staff is providing individual data reports to management on a monthly basis. Case processing timeframes and the completed case flow maps have been incorporated into the enforcement policy and procedure manuals.

In a meeting on February 10, 2017, with the Division of Investigation (DOI) management and the Board of Registered Nursing (BRN) Intake and Investigation Chief, an agreement was made to establish the Investigation timeframe goal for both DOI and BRN at 240 days. This agreement was confirmed in writing with all parties and documented in the Investigation 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 us with documentation to support its claim that it has fully implemented this recommendation.

  • Auditee did not substantiate its claim of full implementation

60-Day Agency Response

Through collaborative efforts with DCA's BreEZe Business Integrity Analysts (BIAs), Executive management, SOLID staff, and BRN enforcement managers and staff, the BRN has developed the following business processes:

- A detailed workflow mapping of complaint intake and investigation business processes,

- Updated policies and procedures to direct staff action to ensure the assignment of cases to appropriate investigation unit or expert witnesses,

- Ongoing (bi-weekly) communication with BRN staff regarding process improvement and outcomes,

- Updated policies and procedures to include timeframe expectations for each stage of complaint and investigation resolution process,

- A robust set of milestone reports were developed and implemented to track each key stage of the complaint resolution and investigation processes to provide management with accurate data regarding case processing timeframes,

- An average of 240 days was established as a reasonable goal for DOI and BRN to complete the investigation process. BRN and DOI will continue to work collaboratively to examine ways to improve efficiencies.

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

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

Although BRN developed formal policies that specify time frames for some key stages of the complaint resolution process, it did not specify time frames for how quickly complaints should be assigned to the proper investigative unit. Further, BRN could not provide evidence demonstrating that these policies have been approved by, for example, the board or the executive officer, and have been distributed to staff.

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

Recommendation #6 To: Registered Nursing, Board of

To ensure that BRN resolves complaints regarding nurses in a timely manner, by March 1, 2017, it should establish a formal, routine process for management to monitor each key stage of the complaint resolution process to determine whether the time frames are being met, the reasons for any delays, and any areas in the process that it can improve.

6-Month Agency Response

Timeframe/Milestone reports are completed and in full production mode as of March 1, 2017. Reports are delivered on a monthly basis to all enforcement unit managers.

As of April 14, 2017, instructions for managers to use the Timeframe/Milestone reports when evaluating staff workload are included in the Management Monitoring Plans.

In reviewing the reports recommended by the audit the BRN designed additional reports to track Decisions & Appeals, as well as Citation and Fine workloads. These new reports are in final testing stages with the Department of Consumer Affair's (DCA) Office of Information Services. Scheduled implementation of these new reports is anticipated by July 1.

  • Completion Date: May 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
  • Auditee did not address all aspects of the recommendation

60-Day Agency Response

DCA BreEZe BIAs and BRN Subject Matter Experts (SME) worked collectively to develop a series of data reports (i.e. 50 sets) for use in all enforcement units. These reports will allow Managers to identify areas of delays, track team and individual performance, and address process improvements with supervisors and staff.

All reports are in production as of February 1st which will be used by managers to monitor each key stage of the complaint resolution process to ensure time frames are being met, identify reasons for any delays, and potential process improvements.

Each unit has developed a management monitoring plan instructing supervisors in report utilization, timeframe monitoring, and ongoing audits of staff case workload.

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

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

Although BRN developed a number of reports that if used would show how long staff are taking to process complaints, it did not develop policies and procedures that specifically direct managers to, or detail how they should, use these reports to routinely monitor each key stage of the complaint resolution process to assess whether staff are meeting set time frames, the reasons for delays, and any areas for improvement. Until these shortcomings are addressed, we will report this recommendation as partially implemented.

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

Recommendation #7 To: Registered Nursing, Board of

To ensure that BRN resolves complaints regarding nurses in a timely manner, by March 1, 2017, it should establish a plan to eliminate its backlog of complaints awaiting assignment to an investigator.

6-Month Agency Response

The BRN eliminated the unassigned case backlog prior to the 60-day response and continues to have no backlog of unassigned cases. 60-day feedback from auditor outlines concerns regarding Investigator workload. BRN believes additional staff will be necessary to address the level of workload assigned to investigators and is in the process of reviewing workload and staffing resources to determine what is needed.

  • Completion Date: January 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

As of January 17, 2017, the BRN has eliminated any unassigned backlog in the BRN Investigation Unit.

Immediately following release of the audit report, case assignments were increased for all investigators from 20 to 25 each which aided in the elimination of the backlog. The BRN developed procedures requiring a case received by the investigations unit to be assigned to a Supervising Special Investigator (SSI) within 10 business days. The SSI is responsible for reviewing and triaging the incoming case workload of the unit. Cases will remain assigned to the SSI until the field investigator's workload allows the case to be assigned to the field investigator. This process has been updated and included in the policies and procedures for investigations. In addition, the BRN began strictly adhering to the Division of Investigation's CPEI case referral guidelines which has also contributed to elimination of the backlog.

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

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

BRN indicated that it eliminated its backlog of complaints awaiting assignment to an investigator by assigning them to its investigators. Based on documentation provided by BRN, this increased investigators' caseload, on average, to roughly 24. However, as we describe in our audit report on pages 28 to 29, the chief of investigations acknowledged that a full caseload for BRN's non-sworn investigators is 20 complaints. Therefore, rather than BRN eliminating its backlog, it simply shifted the backlogged complaints by assigning them to its non-sworn investigators who already have full caseloads. Until it can demonstrate that its non-sworn investigators are able to timely resolve complaints, given the increased caseload, we will report this as partially implemented.

  • Auditee did not substantiate its claim of full implementation

Recommendation #8 To: Registered Nursing, Board of

To increase its pool of expert witnesses, by June 2017, BRN should develop and implement a process to track the effectiveness of the methods it uses to recruit expert witnesses, and then focus its efforts on those methods that prove to be the most successful.

6-Month Agency Response

The Expert Witness program has been re-branded and is now called the Expert Practice Consultant (EPC) program. The application has been updated and published to the BRN website.

A recruitment flyer for EPC is now included with all BRN paper renewal notices in the mail. This has resulted in a substantial increase of 61.5% EPC applications received. The success in the number of EPC applications is due to collaboration with DCA's Public Information Office (PIO) and BRN outreach efforts to nursing program Deans and Directors, the California Hospital Association, professional nursing organizations and use of social media.

The internal EPC database has been updated to capture recruiting data and more accurately capture hours and cost. Recruitment data will be evaluated annually or as needed to determine the most effective recruitment technique.

  • Completion Date: June 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 an effort to increase its expert witness pool, the BRN has implemented the following:

- Updated Expert Witness application and uploaded the document on the BRN Website.

- Contacted DCA Public Information Office (PIO) to develop a detailed marketing plan to recruit additional Expert Witnesses.

- PIO will develop an initial proposal, and present marketing materials for review to the BRN by March 8, 2017.

- Final production date for Expert Witness Marketing Plan is March 29, 2017.

- BRN Expert Witness Database was updated to capture recruiting data and track effectiveness of recruitment methods.

  • Estimated Completion Date: June 2017
  • Response Date: February 2017

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

BRN did not provide any documentation demonstrating that the actions they have claimed to take thus far, were indeed taken. As a result, we are assessing the status of this recommendation as pending, given BRN indicates it will fully implement the recommendation.


Recommendation #9 To: Registered Nursing, Board of

To increase its pool of expert witnesses, by June 2017, BRN should modify its renewal application process for nurses' licenses to include a question regarding whether they would be interested in serving as an expert witness, and then develop a process to promptly follow-up with those nurses.

6-Month Agency Response

A paper renewal mail insert has been developed and is included in all mail renewal notices beginning February 2017.

On March 6, 2017, a request was made to BRN's BreEZe Subject Matter Experts (SME) to include an additional online renewal question regarding the RNs interest in becoming an Expert Practice Consultant. An information technology ticket was initiated and changes to the system will be made according to the BreEZe schedule.

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

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


60-Day Agency Response

A marketing insert was developed for the renewal application and is scheduled for distribution to all renewal licensees beginning with the February 2017 mailing.

In addition, BRN staff is working with the BIAs to develop recruitment efforts using the online renewal application via the BreEZe.

  • Estimated Completion Date: June 2017
  • Response Date: February 2017

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


Recommendation #10 To: Registered Nursing, Board of

To increase its pool of expert witnesses, by June 2017, BRN should take the steps necessary to increase the hourly wage it pays expert witnesses.

6-Month Agency Response

The BRN has contacted three other healing arts boards, Board of Vocational Nursing and Psychiatric Technicians, Medical Board of California and Board of Psychology, to determine an average Expert Practice Consultant wage to be paid per hour.

On January 6, 2017, BRN completed a report of expert hours by profession in order to project the overall impact to the BRN budget.

The BRN would like to increase the expert fee to $100 for RNs, $125 for Advanced Practice Registered Nurses (APRN), $150 for psychologists and $200 for Psychiatrists, effective July 1, 2018. The Board is actively working to identify resources to allow it to implement these increased costs.

  • Estimated Completion Date: July 2018
  • Response Date: June 2017

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


60-Day Agency Response

BRN has benchmarked the hourly rate for expert witnesses of three other healing arts boards (e.g. BVNPT, MBC and Psychology) to determine an average hourly wage.

BRN staff proposes raising the rate for all expert witnesses to include the following: $75 to $100 per hour for RNs, $125 to $150 for psychologists, and $175 to $200 per hour for psychiatrists. A proposal will be submitted in or about April 2017 in accordance with the budget cycle.

  • Estimated Completion Date: June 2017
  • Response Date: February 2017

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


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.

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

Recommendation #12 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 immediately begin working with Consumer Affairs to implement cost-effective input controls for BreEZe that will require BRN staff members to enter information into a complaint record in a way that is consistent with BRN's business processes, as well as to implement changes that would cause BreEZe to accurately identify the order in which activities occur.

6-Month Agency Response

BRN SMEs worked with the DCAs Business Integrity Analysts (BIA) to develop activity code functionality to allow stop gap controls in the BreEZe system which will accurately identify the order activities occur. Prioritization of BreEZe activities is a global issue that will impact all DCA boards and bureaus that utilize the BreEZe system. Implementing stop gap controls requires approval from the following workgroups: DCA's Enforcement User Group and Reports User Group, BreEZe Vendor, and Change Control Board.

A System Investigation Request (SIR) was submitted by BRN SMEs on December 16, 2016, to DCA which was approved to go to the BreEZe Vendor for scope-of-work review and approval. Once the BreEZe Vendor returned the SIR with the scope-of-work approved, changes were then submitted as a work authorization to DCA's Change Control Board to approve the BreEZe stop gap controls. The Change Control Board approved the Work Authorization to be forwarded for Impact Analysis. This Impact Analysis is currently pending. The BRN will continue to work with these groups to update the business process and evaluate the cost-effectiveness of implementing this practice.

Per DCA, the implementation of this type of change typically takes about one year to complete.

  • Estimated Completion Date: January 2018
  • Response Date: June 2017

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


60-Day Agency Response

BRN SMEs have worked with the BIAs to develop activity code functionality to allow stop gap controls in the BreEZe system which will accurately identify the order activities occur. Prioritization of BreEZe activities is a global issue that will impact all DCA boards and bureaus that utilize the BreEZe system. Implementing stop gap controls will require approval from the following workgroups: DCA's Enforcement User Group and Reports User Group, BreEze Vendor, and Change Control Board. A System Investigation Request (SIR) was submitted by BRN SMEs on December 16, 2016, to DCA which was approved to go to the BreEZe Vendor for scope-of-work review and approval. Once The BreEZe Vendor returned the SIR with the scope-of-work approved, changes were then submitted as a work authorization to DCA's Change Control Board to approve the BreEZe stop gap controls. The Change Control Board approved the Work Authorization to be forwarded for Impact Analysis. This Impact Analysis is currently pending. The BRN will continue to work with these groups to update the business process and evaluate the cost-effectiveness of implementing this practice. Per DCA, the implementation of the process typically takes about one year to complete.

  • Estimated Completion Date: Unknown
  • Response Date: February 2017

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


Recommendation #13 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, once it has implemented cost-effective input controls for BreEZe and accumulated six months of data, BRN should analyze these data to determine whether its staffing is sufficient to meet its workload.

6-Month Agency Response

Data reports were released to managers for review in March 2017. The 6-month data accumulation mark will be in September 2017. Reports have been reviewed for the previous six months. BRN will continue to monitor these reports monthly until we have the upcoming six months' worth of data. Analysis of the data will be used to determine whether additional staffing is necessary to meet its workload.

  • Estimated Completion Date: October 2017
  • Response Date: June 2017

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


60-Day Agency Response

If input controls are approved by the Enforcement User Group and implemented in BreEZe, the BRN will accumulate and analyze six months of data to determine if staffing needs are sufficient to meet its current workload.

  • Estimated Completion Date: Unknown
  • Response Date: February 2017

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


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.

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

Recommendation #15 To: Registered Nursing, Board of

BRN should immediately comply with state law and adhere to the revised CPEI guidelines that DOI issued in August 2016. Additionally, BRN should establish and maintain a process for communicating with DOI to discuss any questions that arise in assigning a priority to a complaint or referring a complaint to the proper investigative unit.

6-Month Agency Response

Instructions have been incorporated into the Complaint Intake Unit Procedure manual, which has been implemented into normal staff practice. Data verified in BreEZe shows full compliance with CPEI case referral guidelines as of December 2016.

Staff instructions for the use of CPEI guidelines, resolution of CPEI application questions, and communication with DOI regarding CPEI can be verified on pages 77-79 of the Complaint Intake Unit Procedure manual.

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

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

BRN developed complaint intake procedures that include a copy of the revised CPEI guidelines DOI issued in August 2016, and that direct staff to adhere to the CPEI guidelines when assigning complaints. However, although these procedures direct staff to assign those complaints with allegations that clearly fall into categories 1 or 2 to DOI, they also instruct staff to assign complaints with vague allegations, or those that do not exactly fall within categories 1 or 2, to BRN's investigative unit without discussing them with DOI. By not communicating with DOI regarding the assignment of these types of complaints, BRN risks not assigning these complaints to the appropriate investigative unit.

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

60-Day Agency Response

Complaint Intake Staff have been trained and provided desk copies of the DCA Case Referral Guidelines for Investigations (Guidelines). Complaint Intake Staff Services Analysts evaluate complaints and refer cases to BRN or DOI investigations as required by the Guidelines.

Complaint Intake Policies and Procedures have been written to formalize the process.

Beginning December 2016, BRN management and DOI have met on several occasions to discuss ongoing case referral and priority issues. Since then, formally scheduled monthly meetings have been conducted to maintain constant communication regarding enforcement matters. Additional meetings will be scheduled as often as needed to ensure that the CPEI case referral guidelines and other matters of concern are being addressed in a timely manner.

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

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

Although BRN developed complaint intake procedures that include a copy of the revised CPEI guidelines that DOI issued in August 2016, these procedures do not direct staff that they must adhere to the CPEI guidelines. The procedures also do not outline a process for communicating with DOI to discuss any questions that arise in assigning a priority to a complaint or referring a complaint to the proper investigative unit.

  • Auditee did not address all aspects of the recommendation

Recommendation #16 To: Registered Nursing, Board of

To ensure that BRN and DOI consistently conduct adequate investigations and obtain sufficient and appropriate evidence to discipline nurses accused of violating the Nursing Act if warranted, BRN in collaboration with Consumer Affairs should implement a mechanism by March 2017 to track and monitor supplemental investigation requests that result from investigators' failure to obtain required documentation or sufficient evidence and use this information to mitigate the causes of these failures.

6-Month Agency Response

BRN Subject Matter Experts worked with DCA BreEZe staff to create additional activity codes which identify the source of supplemental investigation (AGO, Expert, Board, Other), and the type of evidence requested (i.e. obtain records, interviews, subpoenas). Staff coding procedures that require they document the reason for the supplemental investigation can be found on page 83 of the Complaint Intake Unit Procedure manual.

BRN updated the Complaint Intake Unit procedures for staff to identify the reason why a supplemental investigation is conducted in the activity results text box for the supplemental investigation activity code.

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

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

Although BRN's Complaint Intake Unit Procedures direct staff to identify the reason why a supplemental investigation is conducted in BreEZe, it did not provide documentation demonstrating that BreEZe indeed contains this functionality.

  • Auditee did not substantiate its claim of full implementation

60-Day Agency Response

BRN SMEs have submitted SIRs to add additional activity codes to include all reasons why a supplemental investigation would be requested (i.e. obtain records, interviews, subpoenas).

The new/updated BreEZe activity codes, which will capture more detailed information regarding the origin and scope of supplemental investigation requests, have been developed and are scheduled to be implemented in the next BreEZe software release by the end of February 2017.

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

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

Although BRN implemented a mechanism in BreEZe on February 21, 2017 to allow it to track who requests a supplemental investigation and whether the request was for an interview, subpoena, or other documentation, this new mechanism does not allow BRN to identify or track whether the reason for the supplemental investigation request was the result of an investigator's failure to obtain required documentation or sufficient evidence during the initial investigation. Without this information, BRN is hindered in its ability to mitigate the causes of investigators' failure to obtain required evidence.

  • Auditee did not address all aspects of the recommendation

Recommendation #17 To: Registered Nursing, Board of

To ensure that BRN and DOI consistently conduct adequate investigations and obtain sufficient and appropriate evidence to discipline nurses accused of violating the Nursing Act if warranted, BRN in collaboration with Consumer Affairs should coordinate with the Attorney General to develop a biennial training program that includes techniques for gathering appropriate evidence and ensure that all investigators, including DOI's investigators, participate in this training.

6-Month Agency Response

With the coordination of the AGO and participation of DCA's SOLID Training Solutions, DOI, and BRN staff; the BRN implemented a formal training curriculum developed by the AGO for DOI and BRN investigation staff.

The training was designed to educate BRN and DOI investigators in case development and evidentiary issues related to BRN complaints, as well as a description of what constitutes sufficient evidence when investigating BRN complaints.

As of March 22, 2017, all BRN and DOI investigators completed this training.

The training session on March 22nd was recorded and provided to BRN and DOI to make available to future new investigators as part of their required training.

This training requirement has been added to the BRN Investigator training plan in the Investigation Unit Procedure manual.

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

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

BRN did not provide documentation demonstrating it coordinated with the Attorney General in developing the training, evidence demonstrating that the training occurred, or documentation indicating the training is required. Until it provides such evidence, we will continue to report this recommendation as not fully implemented.

  • Auditee did not substantiate its claim of full implementation

60-Day Agency Response

With the coordination of the Attorney General's Office and participation of DCA's SOLID Training Solutions, DOI, and BRN staff; the BRN has worked aggressively over the past six weeks to develop a formal training curriculum for DOI and BRN investigation staff. This training is designed to educate BRN and DOI investigators in case development and evidentiary issues related to BRN complaints, as well as a description of what constitutes sufficient evidence when investigating BRN complaints.

The outline of the training curriculum has been developed. The final curriculum, training materials, and training presentation are being developed by the AG's office. Training for all investigative staff is scheduled to be complete March 22, 2017. The BRN will record one of the sessions which will be used as an exemplar in the future for newly hired investigative staff. Staff will be required to attend biennial training sessions. This requirement has been added to the investigator training plan in the policy and procedure manual.

  • Estimated Completion Date: March 22, 2017
  • Response Date: February 2017

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

BRN did not provide any documentation demonstrating that the actions they have claimed to take thus far, were indeed taken. As a result, we are assessing the status of this recommendation as pending, given BRN indicates it will fully implement the recommendation.


Recommendation #18 To: Registered Nursing, Board of

To ensure that BRN and DOI consistently conduct adequate investigations and obtain sufficient and appropriate evidence to discipline nurses accused of violating the Nursing Act if warranted, BRN in collaboration with Consumer Affairs should use this training program to develop a procedural guide that specifies proper evidence-gathering techniques, including a description of what constitutes sufficient evidence, for investigators to follow when investigating complaints. They should then distribute this guide to all investigators, including DOI's investigators, by December 2017, and jointly instruct them to adhere to the guide when conducting investigations.

6-Month Agency Response

The manual developed for Investigator Training as required in Auditor Recommendation #17, specifies proper evidence-gathering techniques, including a description of what constitutes sufficient evidence, for investigators to follow when investigating complaints. The manual was disseminated at the trainings held in March 2017. The training manual has been digitized and is available via the BRN Investigation shared network.

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

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

BRN did not provide evidence demonstrating that it has specified proper evidence-gathering techniques in its procedures and did not submit documentation indicating it had provided such direction to staff in its March 2017 training. Further, it did not provide documentation demonstrating that it distributed direction regarding proper evidence-gathering techniques to all investigators, including DOI's investigators. Until it does so, we will continue to report this recommendation as not fully implemented.

  • Auditee did not substantiate its claim of full implementation

60-Day Agency Response

Once the two training sessions for BRN and DOI investigators have concluded, BRN will meet with DOI, SOLID, and AG to assess effectiveness of training materials and convert the training manual into a procedural guide manual that will be distributed to all BRN and DOI investigators with instructions to adhere when conducting investigations. This completion and distribution of this guide to staff is scheduled on or before December 2017.

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

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


Recommendation #19 To: Registered Nursing, Board of

To ensure that its enforcement unit employees appropriately address and process complaints in a consistent and efficient manner, by March 2017, BRN should develop a process to centrally track the internal and external trainings its staff participate in. On a regular basis, managers should review this information to ensure enforcement staff are participating in a timely manner in appropriate trainings that address the enforcement activities they specifically perform and the types of complaints they may investigate.

6-Month Agency Response

Managers were given data from SOLID training solutions which outline all training records for BRN Staff. BRN created a centralized database to track existing and future training data for staff. This database is updated on an ongoing basis by the supervisors as training is completed.

Management Monitoring Plans have been updated to include staff training plans by classification.

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

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

Although BRN developed a database to centrally track internal and external trainings its enforcement staff have taken, it has not developed a process to ensure that managers regularly review that information to ensure enforcement staff are participating in appropriate trainings that address the enforcement activities they specifically perform and the types of complaints they may investigate.

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

60-Day Agency Response

Data from SOLID training solutions which outlines all training records for BRN Staff was obtained and customized for all areas of BRN to centrally track all internal and external trainings of staff participation.

Management monitoring plans have been updated to include minimum training requirements for all levels of enforcement staff. Managers will review and evaluate on an annual basis, or as needed, all trainings that have been completed by staff as well as any identified additional training related to types of complaints and investigations.

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

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

Although BRN developed a listing of internal and external trainings its enforcement staff have taken, it has not developed a process to centrally track the internal and external trainings or to ensure that managers review that information to ensure enforcement staff are participating in appropriate trainings that address the enforcement activities they specifically perform and the types of complaints they may investigate.

  • Auditee did not address all aspects of the recommendation

Recommendation #20 To: Registered Nursing, Board of

To ensure that its enforcement unit employees appropriately address and process complaints in a consistent and efficient manner, BRN should implement a formal training program no later than December 2017. In developing this program, BRN should consult with DOI and the Attorney General to identify training that could benefit its enforcement staff, and also solicit input of its enforcement staff on areas of their job duties where they believe they need additional training.

6-Month Agency Response

BRN has consulted with DOI, AGO and DCA to review and revise the DCA Enforcement Academy to address the various areas of enforcement. BRN enforcement management and staff have worked with DCA SOLID staff as subject matter experts in redesigning the DCA Enforcement Academy. The formal training courses will be taught in-person by SOLID staff and Subject Matter Experts (beginning January 2017) will include but are not limited to:

- Basics of Enforcement

- BreEZe Enforcement Training

- Complaint Intake

- Investigation Techniques

- Leadership and Safety in the Field

- Interview Techniques for Investigators

- Investigative Report Writing

- Courtroom Testifying

- Probation Monitoring

- Investigative Subpoena Preparation

Additional courses are currently in development for other areas of enforcement. The training courses will be monitored and managed by supervisors to ensure all staff completes these training courses in a timely manner.

Management monitoring plans have been updated to include minimum training requirements for all staff.

BRN enforcement management will work with DCAs SOLID to disseminate a training survey to solicit input from enforcement staff on areas of their job duties where they believe they need additional training. The information collected from the survey will be considered in developing additional training for staff.

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

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


60-Day Agency Response

BRN has consulted with DOI, AGO and DCA to review and revise the DCA Enforcement Academy to address the various areas of enforcement. BRN enforcement management and staff have worked with DCA SOLID staff as subject matter experts in redesigning the DCA Enforcement Academy. The formal training courses (available beginning January 2017) will include but are not limited to:

- Basics of Enforcement

- BreEZe Enforcement Training

- Complaint Intake

- Investigation Techniques

- Leadership and Safety in the Field

- Interview Techniques for Investigators

- Investigative Report Writing

- Courtroom Testifying

- Probation Monitoring

- Investigative Subpoena Preparation

Additional courses are currently in development for other areas of enforcement. The training courses will be monitored and managed by supervisors to ensure all staff completes these training courses in a timely manner.

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

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


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.

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

Recommendation #22 To: Registered Nursing, Board of

BRN should continue working with Justice and Consumer Affairs and finalize its reconciliation, by March 1, 2017, of Justice's fingerprint data with its data in BreEZe to identify any nurses who are missing fingerprint records. Once this reconciliation is performed, BRN must take the steps necessary to immediately obtain fingerprints from those nurses for which Justice has no fingerprint records.

6-Month Agency Response

All data reconciliation actions with the Department of Justice (DOJ) are complete and BRN is taking steps necessary to immediately obtain fingerprints from those nurses for which neither BRN nor DOJ has fingerprint records.

BRN identified approximately 16,000 current and active RN's missing fingerprint data. From December 2016 to present, BRN has processed approximately 10,100 notification letters to licensees with deficient fingerprint data. There are approximately 5,900 licensees remaining to be contacted. BRN is currently in the process of contacting the remaining individuals not in compliance with the fingerprint requirement.

Approximately 440 current and active licensees who failed to comply with the fingerprint notifications were referred to the Enforcement Division for possible disciplinary action.

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

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


60-Day Agency Response

Both BRN and DCA have been in communication with Department of Justice (DOJ) to complete the reconciliation of fingerprint records. To reconcile fingerprint data, the BRN needs DOJ's fingerprint database results in order to compare BRN BreEZe fingerprint records to determine which licensees still require fingerprint results. BRN will continue to work with DCA to identify any fingerprint data not available in BreEZe and that require licensee's to furnish fingerprints to the DOJ as required by law. BRN will also continue to collaborate with DCA to obtain updated fingerprint information from DOJ to reconcile all licensee records.

Using the fingerprint data received from DOJ in May 2016 the BRN is actively seeking fingerprint results for any licensee in BreEZe where records do not exist in an effort to update the data in the BreEZe system. The BRN has taken the following steps to notify licensees about the fingerprint renewal requirement:

- Initial and follow-up letters and e-mails have been mailed out to licensees where no fingerprint results exist in BreEZe or DOJ

- The BRN website has been updated with information regarding this requirement

- Announcements have been made at recent BRN board meetings held in January and February 2017

- A social media campaign has been launched in collaboration with DCA on FaceBook and Twitter regarding the fingerprint renewal requirement

- BRN executive management has met with nursing professional organizations (e.g. Hospital Association, ACNL, CNA, SEIU, UNAC, and ANA-C) who have shared this information with their nursing constituent groups throughout the state

- A telephone hotline and e-mail address were established to respond to the effected licensees

- Nurses who received the notification letters and do not comply with the requirement will be noticed and referred to enforcement for possible disciplinary action

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

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

Although BRN has taken steps to obtain the fingerprints from those nurses for which it knows are lacking fingerprints from the May 2016 Justice data, it still has not finalized its reconciliation of Justice's fingerprint data with its data in BreEZe to identify any nurses who are missing fingerprint records. Until it has done so, this recommendation is not fully implemented.

  • Auditee did not address all aspects of the recommendation

Recommendation #23 To: Registered Nursing, Board of

To ensure that it has prompt access to adequate information that could affect the status of a nurse's license, by June 2017, BRN should establish formal agreements with other agencies and other health boards that have information pertaining to a nurse's misconduct.

6-Month Agency Response

BRN is currently finalizing an agreement for data sharing between the California Department of Public Health (CDPH) and the BRN. The document is currently being reviewed by CDPH legal. A final agreement is anticipated by July/August 2017.

BRN and the California Department of Corrections and Rehabilitation (CDCR) have discussed preliminary procedures for exchange of information for BRN complaints. Discussions are ongoing.

BRN's EO met with various Nursing and Hospital Associations to discuss possible solutions in an effort to obtain timely evidence during BRN investigations. Discussions are ongoing.

On May 31, 2017, BRN's EO, Assistant EO and Chief of Discipline, Probation and Intervention met with DCA's Director and Chief Deputy Director to discuss Memorandums of Understanding (MOU). The Director stated DCA will take the lead on this to assist all boards and bureaus regarding sharing enforcement information.

Any agreement entered into by the board/bureau will conform to Business and Professions Code section 11180 etc. to ensure any agreement or MOU drafted either by DCA or as a result of a delegation granted by the Director is compliant with Business and Professions Code section 11183 so as to maintain the confidential nature of the information shared.

BRN considers this item to be partially implemented pending additional action from community partners.

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

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


60-Day Agency Response

To ensure the BRN has prompt access to adequate data, the BRN has met with the California Department of Public Health (CDPH), California Department of Corrections and Rehabilitation (CDCR), and DCA's healing arts boards to discuss establishing formal agreements and/or memorandums of understanding (MOU) to share data that includes a nurse's misconduct and other pertinent information.

The BRN's EO met with several healing arts board's EO's in December 2016 to initiate discussion of establishing routine meetings regarding mutual issues of concern. Meetings will be scheduled on a quarterly basis. A more formal MOU will be presented to DCA's Legal Office for review which will allow all healing arts boards within DCA to share information.

Initial meetings were held with CDCR and CDPH during the month of January 2017. Follow-up meetings are scheduled to formalize the MOU process pending legal approval of the agreements by all involved parties.

  • Estimated Completion Date: June 2017
  • Response Date: February 2017

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


Recommendation #24 To: Registered Nursing, Board of

To ensure that it has prompt access to adequate information that could affect the status of a nurse's license, by June 2017, BRN should work with Consumer Affairs and other health boards to determine whether modifying BreEZe to include a capability that would allow it to promptly notify BRN when another health board receives a complaint or takes disciplinary action against a licensed nurse is cost-effective. If it is, add this functionality to BreEZe.

60-Day Agency Response

The BRN SMEs worked with DCA's BIA to develop an Alert function that is ready to be deployed in the next BreEZe software release at the end of February 2017.

The BreEZe update will include an "Entity Level" alert which will notify BRN staff when another board and/or bureau in BreEZe has taken one of the following actions on a mutual licensee:

- Opened a new complaint, or

- Discipline against a license.

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

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

BRN provided documentation demonstrating that functionality was added to BreEZe to allow BRN to receive automatic notifications when another health board using BreEZe receives a complaint or takes disciplinary action against a licensed nurse.


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

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.

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.