April 2013 FLORENCE COMPLEX
Corrective Action Plans for PerformanceMeasure: Sick Call (Q)
1 Is sick call being conducted five days a week Monday through Friday (excluding holidays)? P-E-07, DO
1101, HSTM Chapter 5, Sec. 2.04.2, Chapter 7, Sec. 7.6]
Level 1 Amber User: Jen fontaine Date: 4/27/2013 9:28:34 AM
Corrective Plan: Nursing Encounter Tools (NETS) have been approved by ADC and implemented on all units.
These are considered nursing protocols and list complaint (subjective ) , VS, including weight when indicated
(objective), (plan) treatment and or referral, (education). HNR's are collected daily and triaged accordingly and
Nurse line is being done five days a week. Urgent HNR's will be addressed after hours or weekends as needed.
Corrective Actions: See above.
2 Are sick call inmates being triaged within 24 hours(or immediately if inmate is identified with emergent
medical needs)? [P-E-07, DO 1101, HSTM Chapter 5, Sec. 3.1]
Level 1 Amber User: Jen fontaine Date: 4/27/2013 9:58:55 AM
Corrective Plan: Nursing Encounter Tools (NETS) have been approved by ADC and implemented on all units.
These are considered nursing protocols and list complaint (subjective ) , VS, including weight when indicated
(objective), (plan) treatment and or referral, (education). HNR's are collected daily and triaged accordingly and
Nurse line is being done five days a week. Urgent HNR's will be addressed after hours or weekends as needed.
Corrective Actions: See above.
3 Are vitals signs, to include weight, being checked and documented each time an inmate is seen during
sick call? [P-E-04, HSTM Chapter 5, Section 1.3]
Level 1 Amber User: Jen fontaine Date: 4/27/2013 10:27:11 AM
Corrective Plan: Nursing Encounter Tools (NETS) have been approved by ADC and implemented on all units.
These are considered nursing protocols and list complaint (subjective ) , VS, including weight when indicated
(objective), (plan) treatment and or referral, (education). HNR's are collected daily and triaged accordingly and
Nurse line is being done five days a week.
Corrective Actions: See above.
4 Is the SOAPE format being utilized in the inmate medical record for encounters? [DO 1104, HSTM Chapter
5, Section 1.3]
Level 1 Amber User: Jen fontaine Date: 4/30/2013 3:30:32 PM
Corrective Plan: Nursing Encounter Tools (NETS) have been approved by ADC and implemented on all units.
These are considered nursing protocols and list complaint (subjective ) , VS, including weight when indicated
(objective), (plan) treatment and or referral, (education). HNR's are collected daily and triaged accordingly and
Nurse line is being done five days a week.
Corrective Actions: See above.
4 Is the SOAPE format being utilized in the inmate medical record for encounters? [DO 1104, HSTM Chapter
5, Section 1.3]
Level 1 Amber User: Jen fontaine Date: 4/30/2013 3:30:32 PM
Corrective Plan: Nursing Encounter Tools (NETS) have been approved by ADC and implemented on all units.
These are considered nursing protocols and list complaint (subjective ) , VS, including weight when indicated
(objective), (plan) treatment and or referral, (education).
Corrective Actions: See above.
5 Are referrals to providers from sick call being seen within seven (7) days? [P-E-07]
Level 1 Amber User: Jen fontaine Date: 4/27/2013 10:49:58 AM
Corrective Plan: With the recent addition of Locum physicians throughout complex and phyisician assistant in
Central Unit it is expected that this measure will be met. In addition, the NETS (Nursing Encounter Tools)
encompass Subjective, Objective, Plan and Education components which enables the LPN to do sick call as well as
RNs.
Corrective Actions: See above.
6 Are nursing protocols in place and utilized by the nurses for sick call?
Level 1 Amber User: Jen fontaine Date: 4/27/2013 10:57:43 AM
Corrective Plan: Effective 6/7/13, Corizon has rolled out, trained and implemented (NETS) Nursing Encounter Tools
PRR ADC00381

April 2013 FLORENCE COMPLEX
as approved by ADC.
Corrective Actions: See above.

PRR ADC00382

April 2013 FLORENCE COMPLEX

Corrective Action Plans for PerformanceMeasure: Medical Specialty Consultations (Q)
1 Are urgent consultations being scheduled to be seen within thirty (30) days of the consultation being
initiated? [CC 2.20.2.3]
Level 2 Amber User: Jen fontaine Date: 4/27/2013 1:09:15 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: October Action plan submitted by Corizon1.Standardized monitoring process
2.Communicate expectations via FHA/DON at quarterly training Regional office and obtain sign
off sheet to verify
3.Monitoring (UM Audit Tool)
a.Audit tools developed
b.Weekly site results discussed with RVP
c.Audit results discussed a monthly CQI meeting
d.Minutes and audit reported monthly to Regional office for tracking and trending
Responsible Parties = ARMD/RDON/RVP/RCQI/FHA/DON
Target Date -11/30/13
Continue to monitor weekly x 3 weeks, monthly until within compliance, then quarterly; monitoring frequency using
audit tool per audit results.
1. Standardized process to address, to include but not limited to:
a. Approved consults scheduled/documented within 5 days by clinical coordinator
2. Schedule and conduct training for all clinical coordinators
a.Agenda/sign off sheet to verify
3. Monitoring (UM Audit Tool)
a.Audit tools developed
b.Weekly site results discussed with RVP
c.Audit results discussed a monthly CQI meeting
d.Minutes and audit reported monthly to Regional office for tracking and trending
Responsibile Parties = DON/Clinical Systems Business Analyst II/FHA/DON/RDCQI/RVP
Target Date - 11/30/13
Continue to monitor weekly x 3 weeks, monthly until within compliance, then quarterly; monitoring frequency using
audit tool per audit results.
2 Are consultation reports being reviewed by the provider within seven (7) days of receipt? [CC 2.20.2.3]
Level 2 Amber User: Jen fontaine Date: 4/27/2013 1:25:57 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: October Action plan submitted by Corizon1.Standardized monitoring process
2.Communicate expectations via FHA/DON at quarterly training Regional office and obtain sign
off sheet to verify
3.Monitoring (UM Audit Tool)
a.Audit tools developed
b.Weekly site results discussed with RVP
c.Audit results discussed a monthly CQI meeting
d.Minutes and audit reported monthly to Regional office for tracking and trending
Responsible Parties =ARMD/RDON/RVP/RDCQI/DON/
Target Date-11/30/13
Continue to monitor weekly x 3 weeks, monthly until within compliance, then quarterly; monitoring frequency using
audit tool per audit results.
3 Is the utilization and availability of off-site services appropriate to meet medical, dental and mental health
needs? [CC 2.20.2.3]
Level 3 Amber User: Jen fontaine Date: 4/27/2013 1:58:36 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.

PRR ADC00386

April 2013 FLORENCE COMPLEX
Corrective Action Plans for PerformanceMeasure: Medical Records (Q))
1 Are medical records current, accurate and chronologically maintained with all documents filed in the
designated location? [NCCHC Standard P-H-01]
Level 1 Amber User: Jen fontaine Date: 4/30/2013 3:34:46 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Medical Records will regularly file loose papers and monitor charts for thinning utilizing a
reference for medical record chronological order. Continue to monitor.
Responsible Parties = MRL
Target Date= 11/30/13
1 Are medical records current, accurate and chronologically maintained with all documents filed in the
designated location? [NCCHC Standard P-H-01]
Level 1 Amber User: Jen fontaine Date: 4/30/2013 3:34:46 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Medical Records will regularly file loose papers and monitor charts for thinning utilizing a
reference for medical record chronological order. Continue to monitor.
Responsible Parties = MRL
Target Date= 11/30/13
2 Are provider orders noted daily with time, date and name of person taking the orders off? [NCCHC
Standard P-H-01; HSTM Chapter 5, Section 7.0]
Level 1 Amber User: Jen fontaine Date: 4/28/2013 11:37:39 AM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: CAP for Medical Records MGAR Question # 2 – Are provider orders noted daily with time, date,
and name of person taking the order off?
Reinforce with nursing staff to note charts regularly. Continue to monitor.
Responsible Parties = RN/LPN
Target Date= 11/30/13
2 Are provider orders noted daily with time, date and name of person taking the orders off? [NCCHC
Standard P-H-01; HSTM Chapter 5, Section 7.0]
Level 1 Amber User: Mark Haldane Date: 4/29/2013 8:33:39 AM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Reinforce with nursing staff to note charts regularly. Continue to monitor.
Responsible Parties = RN/LPN
Target Date= 11/30/13
4 Are medical record entries legible, and complete with time, name stamp and signature present? [HSTM
Chpt. 5, Section 6.4, CC 2.20.2.5]
Level 1 Amber User: Jen fontaine Date: 4/28/2013 12:00:43 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Reinforce with nursing staff the importance of using name stamps. Continue to monitor
Responsible Parties = RN/LPN
Target Date= 11/30/13

PRR ADC00396

April 2013 FLORENCE COMPLEX
Corrective Action Plans for PerformanceMeasure: Prescribing Practices and Pharmacy
(Q)
2 Are pharmacy polices, procedures forms, (including non-formulary requests) being followed? [NCCHC
Standard P-D-01, CC 2.20.2.6]
Level 2 Amber User: Leslie Boothby Date: 4/26/2013 10:14:34 AM
Corrective Plan: We have conducted a series of pharmacy/renewal audits and prepared a status report for AZ
Regional Pharmacist indicating percentages of med renewals that were ordered/faxed, verified, reviewed, to include
formulary vs approved non-formulary. In most circumstances, the results yielded 100%. We did uncover some areas
of improvement and are in the process of additional staff training.
Corrective Actions: See above.

PRR ADC00398

April 2013 FLORENCE COMPLEX
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: October Action plan submitted by Corizon
1. In-service staff on process expectations per Mental Health 2.20.2.10 contract performance outcome 7 (Mental
Health Attachment) related to re-entry plan
a.SMI patients will be followed by discharge planners utilizing the data from the SMI monthly report tool; MH3
patients will be given community resources by MH Clinicians and documented in the chart; all patients receiving
psychotropic medications will be seen by Psychiatrist/Psychiatry CNP
b.Agenda/sign off sheet to verify, inclusive of all pertinent staff
2. Monitoring (Mental Health Monitoring Tool)
a.Audit tools developed
b.Monthly site results discussed with RVP/MH Director
c.Audit results discussed at monthly CQI meeting
d.Minutes and audit reported monthly to Regional office for tracking and trending
Responsible Parties = FHA/DON/Mental Health Director/RVP/RDON/RDCQI/MH Lead
Target Date- 11/30/13
Will continue to monitor monthly until within compliance, then quarterly; monitoring frequency using audit tool per
audit results.

PRR ADC00404

April 2013 FLORENCE COMPLEX
Corrective Action Plans for PerformanceMeasure: Quality and PEER Review (Q)
1 Is the contractor physician conducting monthly and quarterly chart reviews? [HSTM Chpt. 1, Sec. 5.0; CC
2.20.2.12]
Level 1 Amber User: Jen fontaine Date: 4/30/2013 1:54:28 PM
Corrective Plan: With the on boarding of three new providers, it would be the expectation there will be more time to
conduct chart reviews. We have also approved and implemented use of overtime for mid-level providers who will
come in on the weekends for chart reviews.
Corrective Actions: See above.

PRR ADC00406

April 2013 FLORENCE COMPLEX
Corrective Plan: Effective 6/7/13 we have two Locum (temporary) physicians, one Medical Director and two
physician assistants providing care throughout the complex. This should prove effective in tackling the backlog,
address urgent needs and chronic patients. Mental Health has added an additional RN (filled) and two Psych
Associates (recruiting) to staffing control. Nursing although has seen some turnover, is building an impressive pool
of PRN nurses to be shared with Eyman and be used in place of agency as needed. We continue to recruit for
providers of various disciplines to meet the ever changing needs of the complex.
Corrective Actions: Will continue to monitor.
3 Are all positions filled per contractor staffing pattern?
Level 2 Amber User: Jen fontaine Date: 4/29/2013 8:48:53 PM
Corrective Plan: Effective 6/7/13 we have two Locum (temporary) physicians, one Medical Director and two
physician assistants providing care throughout the complex. This should prove effective in tackling the backlog,
address urgent needs and chronic patients. Mental Health has added an additional RN (filled) and two Psych
Associates (recruiting) to staffing control. Nursing although has seen some turnover, is building an impressive pool
of PRN nurses to be shared with Eyman and be used in place of agency as needed. We continue to recruit for
providers of various disciplines to meet the ever changing needs of the complex.
Corrective Actions: See above.

PRR ADC00413

April 2013 FLORENCE COMPLEX
Corrective Action Plans for PerformanceMeasure: Infirmary Care
2 Are patients always within sight or hearing of a qualified health care professional (do inmates have a
method of calling the nurse?)
Level 1 Amber User: Jen fontaine Date: 4/27/2013 11:13:26 AM
Corrective Plan: Complex Leadership here at Florence is working with Corizon Regional Leadership to develop a
"call system" for isolation cells but we will need collaboration with ADC on implementation of any such system.
See below.
Corrective Actions: Ensure that inmates have a method available to contact nursing staff.
Responsible Parties= RN/LPN
Target Date = 11/30/13
3 Is the number of appropriate and sufficient qualified health professionals in the infirmary determined by
the number of patients, severity of illnesses and level of care required?
Level 1 Amber User: Jen fontaine Date: 4/28/2013 1:29:48 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.
7 Is the frequency of physician and nursing rounds in the infirmary specified based on categories of care
provided?
Level 1 Amber User: Jen fontaine Date: 4/28/2013 1:32:45 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.
11 Are vital signs done daily when required?
Level 1 Amber User: Jen fontaine Date: 4/28/2013 1:37:48 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.
12 Are there nursing care plans that are reviewed weekly and are signed and dated?
Level 1 Amber User: Jen fontaine Date: 4/28/2013 1:41:14 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.
13 Are medications and supplies checked regularly, and who is assigned to do it? [NCCHC Standard P-D03]
Level 1 Amber User: Jen fontaine Date: 4/28/2013 1:44:04 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.

PRR ADC00418