ARIZONA DEPARTMENT OF CORRECTIONS
HEALTH SERVICES CONTRACT MONITORING BUREAU
ASPC-DOUGLAS
MEMORANDUM

TO:

Holly Massey, Corizon FHA

THROUGH: Richard Pratt, ADC HSCMB Program Evaluation Administrator Kathy Campbell, RN, ADC
HSCNM Health Services Coordinator

FROM:

Patricia Arroyo, RN, Nursing Monitor

DATE:

April 5, 2013

SUBJECT:

Compliance Monitoring Activities/Findings for the month of March, 2013.

This memorandum is for the purpose of providing you a recap of the activities and observations I have
encountered during my monitoring visits to the health areas this month.
As March 4, 2013 was the inception of the Corizon / ADC Health Service Contract, and as this required a very
short transition from the previous contract vendor, a formal Monitor findings / corrective action plan was deemed
not practical for this month. Beginning April, 2013, I will once again commence utilizing the M-GAR, and you
and your team will be responsible for providing timely corrective action plans to any negative findings which
may be encountered. Please be assured that while the M-GAR is utilized for the purpose of documenting
negative findings, which in turn require timely written corrective action plans, my commitment to assisting you
and your staff to attain and maintain compliance with ADC policy, the Health Services Contract, and NCCHC
standards remains strong.
CONTRACT INCEPTION: in my opinion, was strong and displayed a real commitment by the corporate
structure of Corizon to partner with ADC in this large and important undertaking. It was very good to see
Corizon Corporate staff at the facility since the middle of February working to ensure as smooth a turnaround as
possible and training the local staff in their duties and responsibilities. While there was a great deal of
understandable anxiety by you and your staff, it was good to see the professional manner in which ALL reacted
to this change.
CHRONIC CARE CLINICS: as you are well aware, chronic care appointments had been pushed to the back
burner. While this was a difficult issue to contend with, with only one mid-level providing all the patient care at
this facility, I am looking forward to great progress being made. The following charts were reviewed, and
Nursing Supervisor was notified. Issues are being addressed.
inmate

, Unable to verify when he was seen for CC appointment.

PRR ADC00296

inmate

: Left Inguinal Hernia repair done in 1/17/13. Provider reviewed dictated note on 1/29/13.
Inmate seen for f/u on 2/26/13.
inmate
: Cardiology AICD interrogation needed. Consult wrote 1/29/13. Call placed to CC
awaiting call return on pending consult.
ADC POLICY, CONTRACT REQUIREMENTS and NCCHC STANDARDS: these three areas are required
to be followed explicitly. If there is ever any question as to how something needs to be accomplished, please
refer to these documents. I am available as a resource and it is my duty, responsibility and desire to help ensure
the success of Corizon Health to provide Constitutionally Mandated Health Care to the Inmate population.
Sincerely,
Patricia Arroyo
c.c Arthur Gross, AD, HSCMB
Helena Valenzuela Compliance Monitor I

PRR ADC00298

PRR ADC00299

Discussion
72 hours recorded as
the timeframe by which
to have screening
processes complete.
ADOC12-00001105
2.9.2

HNRs to be picked up
between 2000 and
0400 and will be triaged
by 0800. HSTM 5.3.1.

“Nursing Assessment
Protocols are clinical
guidelines for licensed
nursing staff when a
practioner is not readily
available or on site.
Using these guidelines,
licensed nursing staff
may initiate protocols
based on their nursing
assessment and/or
observation.” ERO &
NAPs Introduction to
Nursing Assessment
Protocols.

Problem Identified

The physical
examination
completed by a
medical provider by
day two of the intake
process is noncompliant.

Sick call inmates
being seen within 24
hours of the HNR
being triaged (or
immediately if inmate
is identified with
emergent medical
needs) remains noncompliant.

Nursing protocols
remain inconsistently
utilized by the nurses
for sick call and it
appears there is not
a sick call line by
nursing.

Nursing continuously encouraged to use
their clinical judgment and apply NAPs
when observed to be deemed necessary.

Nursing staff trained on process of HNR
collection, triage and treatment line. To be
reinforced at nursing meeting scheduled
for April 17, 2013, where staff will sign
that they have received and
comprehended said policy. Process
compliance to be reviewed on a
continuing basis by DON who will review
weekly with FHA.

Will continue to monitor the Intake
process for compliance with initial
processing, to include: CBC, RPR, PPD
screening, CXR if positive PPD, UA,
Panorax X-ray, 14 Day Mental Health
Assessment, Nursing Screening and
Physical Exam.

Corrective Action Plan

Responsible
Person

Holly Elaine
Massey, RN,
FHA
And
Humberto
Sirvent, DON

Holly Elaine
Massey, RN,
FHA
And
Humberto
Sirvent, DON

Holly Elaine
Massey, RN,
FHA
And
Sheldon Epstein,
SMD

Phoenix
Corrective Action PlanPrepared By: Holly Elaine Massey, FHA

Complete.

In
process.

Complete.

Status

4/19/13

Anticipated
Completion
Date

4/2/13

4/2/13

Date
Completed

PRR ADC00300

Discussion
“All laboratory test
results are to be
reviewed by a medical
provider, psychiatrist, or
dentist. “Panic” values
as outlined by the
contract laboratory are
to be reported to the
appropriate provider
immediately for review
and action, as
necessary. Routine
results will process as
follows:
-Test results are
received by designated
computer(s).
-Results are placed in
the inmate’s medical
record with a
designated review
stamp for provider
review.
-After provider review,
the lab results are filed
in the medical record.”
HSTM 4.2.0.8.0.

Problem Identified

Laboratory results
remain inconsistent
in being provider
reviewed. Lab
results are not being
reviewed by the on
site provider.
Additionally, the lab
results are not
transferred with the
inmate in his medical
record to his
permanent yard in a
timely manner
creating a situation
of unavailability of
laboratory results to
medical staff at the
inmate's permanent
facility.

Medical Records staff to be trained on
policy. Provider Review stamps to be
ordered and readily available to Medical
Records and Nursing staff in Clinic.
MRLS to provide reinforcement and audit
continuously. MRLS to review progress
weekly with FHA.

Corrective Action Plan

Phoenix
Corrective Action PlanPrepared By: Holly Elaine Massey, FHA

Holly Elaine
Massey, RN,
FHA
And
Salvador Salas,
MRLS

Responsible
Person
In
process.

Status

4/23/13

Anticipated
Completion
Date

Date
Completed

Corizon Health
MEMORANDUM
To: Helena Valenzuela, PhD., Health Services Compliance Monitor
From: Holly Elaine Massey, RN, Facility Health Administrator
Date: April 2, 2013
Subject: Response to Monitor Findings for March, 2013 at the Phoenix Alhambra Complex

This memorandum is intended as a response to your investigation into the alleged
compliance issues encountered during the month of March at the Phoenix Alhambra
Complex.
Intake
The physical examination completed by a medical provider by day two of the intake process is
non-compliant as demonstrated by the following inmate medical records:
Inmate
arrive
PE
inmate
2/28/13 3/4/13 -- Arrived 2-28-13 -- PE completed 3-4-13 -- IBU & PCN Prescribed
during PE -- 3-11-13 Extraction by Dr. Sirjani
inmate
3/6/13 3/9/13 -- Arrived 3-6-13 and PE 3-9-13 by Dr. Anikwue & transferred 312-13 -- Healthy no issues
inmate
3/6/13 3/11/13 -- Arrived 3-6-13 and PE completed 3-11-13 - Transferred 3-1213
inmate
3/5/13 3/8/13 -- PE on 3-8-13 No C/C noted by MD
inmate
3/8/13 3/14/13 -- Arrived 3-8-13 -- Prescriptions written 3-8-13 by S. Epstein -PE completed 3-14-13 Transferred 3-15-13
inmate
3/9/13 3/13/13 -- No C/C noted by MD -- MH 3-11-13
inmate
3/7/13 3/12/13 -- No C/C noted by MD
inmate
3/6/13 3/9/13 -- No C/C noted by MD
inmate
3/11/13 3/14/13 -- No C/C noted -- Released on the 3-15-13
Sick call inmates being seen within 24 hours of the HNR being triaged (or immediately if
inmate is identified with emergent medical needs) remains non compliant.
The following inmates have already been transferred without receiving medical or dental
attention for their complaints specified in their HNR and their HNRs remained here on 3/13/15.
HNR:
inmate
HNR dated 3/11 inmate states dental needs/ HNR nurse response on 3/13/13 -No information in this chart regarding this HNR
(All three copies were together indicating inmate did not receive a response) --- No information
in this chart regarding this HNR
inmate
HNR dated 3/11/13 inmate requests filling/ HNR nurse response on 3/13/13 -- No
information in his chart regarding this HNR

PRR ADC00301

HNR dated 3/11/13 inmate states “had cavity filled-tooth hurts bad, gum swollen-this is
an emergency”/ HNR nurse response on 3/12/13”refer to dental” -- Documentation not
received unable to verify
inmate
HNR dated 2/26/13 inmate requests denture supplies/ HNR nurse wrote no response in
the response space --- HNR dates 3-5-13 Picked up on 3-6-13 triaged to Dental per Nursing -- 3-11-13 Dental issued
denture adhesive; #2 HNR date 2-26-13 by inmate answered on the 3-13-13 by dental
indicating that medication was issued on 3-11-13. Dates are not consistent with HNRs.
inmate
HNR dated 3/4/13 -inmate states he is in pain and was scheduled for oral surgery in
county, and that was 7 weeks ago/ HNR response by nurse dated 3/7/13-“refer to dental” Inmate transferred 3-7-13
inmate

Nursing protocols remain inconsistently utilized by the nurses for sick call and it appears
there is not a sick call line by nursing.
Inmate writes he has been taking medication for blood pressure and a blood thinner. He
writes he has a pulmonary embolism and feels lightheaded. Response from nurse on HNR:
“When you see the Dr. be sure to tell him what you need.” -- 3-8-13 RN intake completed -- PE
3-12-12

inmate

HNR inmate request “diabetic shoes” /HNR nurse response: Get at the next yard.
Response was dated 3/7/13-inmate is still here on 3/12/13. -- Transferred 3-6-13 - upon arrival
C/C for I/M states didn't receive shoes -- Good chance in his short time here shoes in his size
were not available.

inmate

HNR inmate states has earache / HNR nurse response: Dr. Line -- Documentation not
received unable to verify

inmate

HNR dated 3/4/13 -inmate states he is in pain and was scheduled for oral surgery in
county, and that was 7 weeks ago/ HNR response by nurse dated 3/7/13-“refer to dental” -NO HNR in chart -- Inmate seen 2-6-13 @1400 and prescribed IBU PRN for pain Inmate transferred 3-7-13

inmate

HNR dated 3/11 inmate states he has a toothache/ HNR response from nurse is to
submit HNR at permanent facility. (All three copies were still together on the HNR indicating
inmate never received response, now, on 3/13/13, inmate has been transferred; however,
his HNR remains here.)
-- Was seen 3-5-13 by Dr. Anikwue for complete PE. No issues on C/C per inmate and doctor. -Inmate transferred 3-11-13

inmate

inmate

HNR inmate states head pain/ HNR nurse response “Dr. Line” -- Inmate transferred 3-14-

13
HNR –inmate states dental pain/HNR response on 3/8/13 from nurse, “Refer to Dental”
(all three pages on the HNR were still together indicating inmate never received a response,
now, on 3/13/13, inmate is transferred; however, his HNR remains here. -- Inmate seen by S.
Epstein on 3-6-13 prescribed IBU & to follow up with Dental at next yard -- Inmate transferred 37-13.

inmate

PRR ADC00302

HNR dated 3/3/13- inmate states socks were taken during a “shake down”; he needs a
sock for his leg brace / HNR nurse response on 3/5/12: “I will contact security.” -- HNR picked up
3-5-13 @0800 -- Response on HRN 3-5-13 @ 0830 -- Inmate transferred A02 3-4-13

inmate

HNR dated 3/4/13 inmate states tooth pain/ HNR response on 3/5/13, will be seen by
dental-HNR remains here on 3/13/13 indicating inmate did not receive a response or was not
evaluated -- Seen by Dr. Redeker on 3-2-13 prescribed IBU & Z-Pack for prn pain -Inmate transferred 3-5-13

inmate

HNR inmate states has “cyst on butt crack”/HNR response from nurse “Dr. Line” -Reoccurring cyst there is multiple documentation regarding this issue -- 3-23-13 F/U with
Dr. Redeker for procedure

inmate

HNR dated 3/4/13 -inmate states he is in pain and was scheduled for oral surgery in
county, and that was 7 weeks ago/ HNR response by nurse dated 3/7/13-“refer to dental” -Double entry -- See above -- NO HNR in chart -- Inmate seen 2-6-13 @1400 and prescribed IBU
PRN for pain - Inmate transferred 3-7-13

inmate

HNR dated 3/11/13 inmate states “had cavity filled-tooth hurts bad, gum swollen-this is
an emergency”/ HNR nurse response on 3/12/13”refer to dental” -- Released in 2001

inmate

HNR dated 3/13/13 inmate complaint is of stomach pains and “gastritis” /HNR nurse
response on 3/14/13 is “Dr Line” -- 3-15-13 seen by Dr. Epstein prescriptions written

inmate

HNR dated 3/13/13 inmate writes “emergency” “teeth hurt” “face swollen” pain/ HNR
nurse response on 3/14/13 is “refer to dental”
-- Documentation not received unable to verify

inmate

LABORATORY RESULTS remain inconsistent in being provider reviewed: Lab results are not
being reviewed by the on site provider. Additionally, the lab results are not transferred with the
inmate in his medical record to his permanent yard in a timely manner creating a situation of
unavailability of laboratory results to medical staff at the inmate's permanent facility.
The following laboratory results were filed in the medical record ready for transfer to the
permanent yard and not provider reviewed:
inmate
-- Arrived 3-11-13, labs collected on the 13th - results received on the 14th &
IM transferred on 3-15-13.
inmate
-- Documentation not received unable to verify
inmate
-- PA Cavanagh reviewed labs & SOAPE documented on 3-11-13
inmate
-- Documentation not received unable to verify
inmate
-- No labs in chart. Arrived 3-11-13 transferred 3-14-13 labs reviewed 3-15-13 at yard
inmate
-- Labs reviewed & SOAPE documentation on 3-11-13 by PA Cavanagh
inmate
-- PE 3-5-13 labs printed 3-15-13 as of 3-18-13 labs given to S. Epstein MD
inmate
-- Documentation not received unable to verify
Medical Record
-- Labs NOT in chart -- Arrived 3-8-13 transferred 3-15

inmate

PRR ADC00303