April 2013 PHOENIX COMPLEX
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 = 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.
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: Helena Valenzuela Date: 4/28/2013 5:04:21 PM
Corrective Plan: Vital Signs, (VS), are to be utilized with every inmate/nursing encounter as required on each
Nursing Encounter Tool, (NET). These VS will not be reflected in the SOAPE notes but on the NET forms. This
process will be again reviewed at the Nursing Meeting scheduled on 5/24/13.
Corrective Actions: Please leave feedback or kindly remove from MGAR. Thank you.
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: Helena Valenzuela Date: 4/28/2013 2:47:24 PM
Corrective Plan: Psychiatrist and Clinical Director, (Mental Health), notified today, (5/24/13), regarding this incident.
Psychiatrist to take special care to assure all medical record entries are complete and legible.
CAP revision #1 - MH Team, led by Clinical Director, will be auditing charts weekly to ensure compliance.
Corrective Actions: Please leave feedback on revision or kindly remove from MGAR. Thank you.
5 Are referrals to providers from sick call being seen within seven (7) days? [P-E-07]
Level 1 Amber User: Helena Valenzuela Date: 4/28/2013 2:58:02 PM
Corrective Plan: On 5/24/2013 MR supervisor counseled regarding the use of outguides. Providers being floated to
Aspen on 5/27/13 and 5/31/13 to avoid backlog.
Corrective Actions: Please leave feedback or kindly remove from MGAR. Thank you.
6 Are nursing protocols in place and utilized by the nurses for sick call?
Level 1 Amber User: Helena Valenzuela Date: 4/28/2013 3:00:43 PM
Corrective Plan: Nursing Encounter Tools are used with standing orders that can be located in the NETs binder
found on every unit. These forms are to be used with every nursing-inmate encounter. The process of completeing
Nursing Encounter Tools, (NETs), will be again reviewed at the Nursing Meeting scheduled on 5/24/13.
9/9/13 - Nursing Encounter Tools are used with standing orders that can be located in the NETs binder found on
every unit. These forms are to be used with every nursing-inmate encounter. The process of completeing Nursing
Encounter Tools, (NETs), will continue to be reviewed on a monthly and ad lib basis.
Corrective Actions: See above

PRR ADC00496

April 2013 PHOENIX COMPLEX
Please be advised that the attached education log needs to be a part of the patients' medical charts, per our
Regional DON. Let's start including these in the new charts we put together on Tuesday, 5/28/13. I will be
conducting audits periodically, beginning on 6/3/13. Education materials are available online, though the nursing
supervisors will be printing out and replacing existing education materials for your ease of availability and have
these in your exam rooms no later than COB on Tuesday, 5/28/13.
Thank you!
Respectfully,
Holly Elaine Massey, RN
Facility Health Administrator'
Corrective Actions: See above.

PRR ADC00500

April 2013 PHOENIX COMPLEX
nurses meetings since then.
Anticipated Completion Date: Ongoing process that will require ongoing monitoring and as such, no date of
completion can be given.
Date Completed: See immediate previous response.
CAP Revision: One nursing supervisor specifically assigned to Aspen to continually monitor this action being
completed. My apologies for not addressing Aspen specifically.
Corrective Actions: Reinforce with nursing staff to note charts regularly. Continue to monitor
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: Helena Valenzuela Date: 4/28/2013 5:12:02 PM
Corrective Plan: Problem Identified: Nursing staff not noting orders in a timely fashion.
Discussion and Action Plan: In response to this finding, the FHA, in conjuction with the DON, has instituted a
process of ensuring that all charts are double checked during the night shift. All charts with orders written during the
day are reviewed by night shift nurses to ensure that all orders are noted within the 24-hour requirement. All nursing
staff have been advised of this requirement and night-shift nurses have been specifically instructed to prioritize this
task to ensure compliance.
Responsible Person: Night Shift Nursing staff for task completion. DON for Accountability and training. FHA for
process development/direction
Status: This process was instituted at the beginning of June, 2013 and has been trained on by the new DON during
nurses meetings since then.
Anticipated Completion Date: Ongoing process that will require ongoing monitoring and as such, no date of
completion can be given.
Date Completed: See immediate previous response.
Corrective Actions: Approved by Helena Valenzuela.
3 Does the Medication Administration Record (MAR) in the medical chart reflect dose, route, frequency,
start date and nurse’s signature? [HSTM Chapter 4, Section 1.1, Chapter 5, Section 6.4]
Level 1 Amber User: Helena Valenzuela Date: 4/28/2013 5:16:32 PM
Corrective Plan: Problem Identified: Incomplete MARs or Missing MARs.
Discussion and Action Plan: As a result of this finding, the FHA and DON have instituted a process of confirming
that all medications currently prescribed for patients have an accurate MAR. The first Monday of each month, the
DON shall run a census (through AIMS) of all inmates in designated housing areas (excluding intakes) and
distribute this census to the nursing staff responsible for those areas. Nursing staff shall then do a chart review of
each patient and confirm that MARs are accurate and present in the MAR books. Nurses shall notate on the census
report if MARs are present and accurate and shall immediately correct or replace any missing or inaccurate MARs.
At the completion of this task, the census report shall be delivered back to the DON for review and a copy of this
report shall be maintained in the DON's office for compliance inspection by contract monitors. These reports shall
be made available on the second Monday of each month. Inventory coordinators may assist in this task as
supervised by nursing staff.
Responsible Person: Nursing staff assigned to units for task completion. DON for review and training. FHA for
process implementation/development/direction.
Status: Initial reviews will begin immediately and the formal process is to begin August 2013. First reports will be
available on August 12th. See below.
Anticipated Completion Date: As this is an ongoing monitoring process, no completion date can be given.
Date Completed: See immediately previous response.
PRR ADC00504

April 2013 PHOENIX COMPLEX
Corrective Actions: Reinforce with nursing staff the importance of a complete MAR. Continue to monitor.
3 Does the Medication Administration Record (MAR) in the medical chart reflect dose, route, frequency,
start date and nurse’s signature? [HSTM Chapter 4, Section 1.1, Chapter 5, Section 6.4]
Level 1 Amber User: Helena Valenzuela Date: 4/28/2013 5:16:32 PM
Corrective Plan: Problem Identified: Incomplete MARs or Missing MARs.
Discussion and Action Plan: As a result of this finding, the FHA and DON have instituted a process of confirming
that all medications currently prescribed for patients have an accurate MAR. The first Monday of each month, the
DON shall run a census (through AIMS) of all inmates in designated housing areas (excluding intakes) and
distribute this census to the nursing staff responsible for those areas. Nursing staff shall then do a chart review of
each patient and confirm that MARs are accurate and present in the MAR books. Nurses shall notate on the census
report if MARs are present and accurate and shall immediately correct or replace any missing or inaccurate MARs.
At the completion of this task, the census report shall be delivered back to the DON for review and a copy of this
report shall be maintained in the DON's office for compliance inspection by contract monitors. These reports shall
be made available on the second Monday of each month. Inventory coordinators may assist in this task as
supervised by nursing staff.
Responsible Person: Nursing staff assigned to units for task completion. DON for review and training. FHA for
process implementation/development/direction.
Status: Initial reviews will begin immediately and the formal process is to begin August 2013. First reports will be
available on August 12th.
Anticipated Completion Date: As this is an ongoing monitoring process, no completion date can be given.
Date Completed: See immediately previous response.
Corrective Actions: Approved by Helena Valenzuela.
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: Helena Valenzuela Date: 4/28/2013 3:20:30 PM
Corrective Plan: Staff redirected/retrained at the monthly staff meeting, held on 5/24/2013. Training ongoing.
Corrective Actions: See above.

PRR ADC00505

April 2013 PHOENIX 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 10:16:34 AM
Corrective Plan: I cannot answer this MGAR as I am not the Regional DON.
Corrective Actions: October Action plan submitted by Corizon1.Standardized process statewide, to include but not limited to (Pharmacy Appendix 1 & 2):
a.Expired Medications (Appendix I.1.a.)
b.Re-order medications
c.Invalid chart orders (Appendix I.1.c.)
i.Therapeutic dose ranges
ii.Dose changes must have supporting documentation
d.Non-formulary process (Appendix I.1.d.)
i.Reviewed for approval within 24-48 hrs
ii.Providers notified decision within 24-48 hrs
e.Manifest Reconciliation
f.Inventory control
g.Stock Medications
h.Practitioner Cards (Appendis I.1.h.)
i.Controlled Medications (Appendix I.1.i.)
2.In-service staff
a.Using information from 8/19 - 11/13 Regional office mandatory in-service and PharmaCorr
policy
b.Agenda/sign off sheet to verify, inclusive of all pertinent staff (Appendix I.2.b.)
3.Monitoring (Appendix I. - IV Monitoring Tools)
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 = FHA/DON/IC/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.
10/11/13 Update – Statewide in Sept Redbook and MAR audit, results reviewed; to audit pharmacy in October
related to Controlled Substances and Expired meds.

PRR ADC00507

April 2013 PHOENIX 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: Helena Valenzuela Date: 4/29/2013 9:38:03 AM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Reinforce with physicians the need to conduct appropriate reviews following DOC/Corizon
guidelines. Continue to monitor.
2 Is contractor conducting monthly CQI committee meetings and meeting NCCHC standard? [P-A-06, HSTM
Chpt. 1, Sec. 5.0; CC 2.20.2.12]
Level 1 Amber User: Helena Valenzuela Date: 4/28/2013 3:25:55 PM
Corrective Plan: 8/17/13 - Problem Identified: No CQI meetings
Discussion and Action Plan: As a result of this finding, the FHA has scheduled a monthly CQI meeting for the third
Tuesday of every month to begin July 16th.
Responsible Person: SMD is responsible for conducting this meeting. Department heads are responsible for
meeting and contributing to CQI activities.
Status: CQI meeting scheduled for July 16th, 2013.
Anticipated Completion Date: As this is an ongoing meeting, no completion date can be given. Meetings to begin
and continue monthly as of August 20, 2013.
Date Completed: See immediately previous response.
8/16/13 - CQI meeting scheduled for 8/27/13. Monitor welcome to attend.
Corrective Actions: CQI Meeting was held on August 27, 2013. Contract Monitor and Nursing Monitor were invited
and declined to attend.
3 Are CQI committee improvement recommendations acted on timely and progress reported back to
committee in the next meeting? [P-A-06, HSTM Chpt. 1, Sec. 5.0; CC 2.20.2.12]
Level 1 Amber User: Helena Valenzuela Date: 4/28/2013 3:26:18 PM
Corrective Plan: 8/16/13 - Problem Identified: No CQI meetings
Discussion and Action Plan: As a result of this finding, the FHA has scheduled a monthly CQI meeting for the third
Tuesday of every month to begin July 16th.
Responsible Person: SMD is responsible for conducting this meeting. Department heads are responsible for
meeting and contributing to CQI activities.
Status: CQI meeting scheduled for Aug 27, 2013.
Anticipated Completion Date: As this is an ongoing meeting, no completion date can be given. Meetings to begin an
continue monthly as of Aug 27, 2013.
Date Completed: See immediately previous response.
Monitor welcome to attend.
Corrective Actions: CQI Meeting was held on August 27, 2013. Contract Monitor and Nursing Monitor were invited
and declined to attend.
5 Did the contractor conduct a quarterly on-site review of the site CQI program? [P-A-06, CC 2.20.2.12]
Level 1 Amber User: Helena Valenzuela Date: 4/28/2013 3:27:50 PM
Corrective Plan: 8/16/13 - Problem Identified: No CQI meetings
Discussion and Action Plan: As a result of this finding, the FHA has scheduled a monthly CQI meeting for the third
Tuesday of every month to begin July 16th.
PRR ADC00514

April 2013 PHOENIX COMPLEX

Responsible Person: FHA is responsible for conducting this meeting. Department heads are responsible for meeting
and contributing to CQI activities.
Status: CQI meeting scheduled for July 27, 2013.
Anticipated Completion Date: As this is an ongoing meeting, no completion date can be given. Meetings to begin an
continue monthly as of July 27, 2013.
Date Completed: See immediately previous response.
Monitor welcome to attend.
Corrective Actions: CQI Meeting was held on August 27, 2013. Contract Monitor and Nursing Monitor were invited
and declined to attend.

PRR ADC00515

April 2013 PHOENIX COMPLEX
Level 1 Amber User: Patricia Arroyo Date: 4/24/2013 11:19:26 AM
Corrective Plan: KOPs are to be included on the MARs, per Corizon policy. This process was educated to the
nurses in the meeting today, (5/24/13), from NEO II binder, under Medication Administration and Documentation,
and is set to begin Tuesday, 5/28/13.
Corrective Actions: Approved.
4 Are the Medication Administration Records (MAR) being completed in accordance with standard nursing
practices? [HSTM Chapter 4, Section 1.1, Chapter 5, Section 6.4]
Level 1 Amber User: Kathy Campbell Date: 4/14/2013 4:10:05 PM
Corrective Plan: Nurses involved with this encounter, (Aspen), have been educated on medication administration
and documentation, counseled and are under corrective actions, where they are being monitored more closely.
CAP Revision #1 - Corizon did all the initial trainings at the Double Tree Suites - I will email out to see if I can aquire
those rosters. NEO II binders are in the medical admin office and much too much to scan into an email. Ms.
Campbell is invited to take one from medical admin at anytime. The next training for NEO II was scheduled for June
3-4, 2013, but due to circumstances beyond our control, has been rescheduled for June 10-11, 2013. Ms. Campbell
welcome to sit in.
Corrective Actions: See above.
4 Are the Medication Administration Records (MAR) being completed in accordance with standard nursing
practices? [HSTM Chapter 4, Section 1.1, Chapter 5, Section 6.4]
Level 1 Amber User: Patricia Arroyo Date: 4/24/2013 11:21:00 AM
Corrective Plan: Nursing meeting today addressed the proper completion of medical record, to include printed
name, signature, and date. Any nurse requiring a name stamp has been asked to submit a request through the Asst
Administrator for order, prior to 5/31/13.
Corrective Actions: See above.
5 Are medication errors forwarded to the FHA to review corrective action plan?
Level 2 Amber User: Kathy Campbell Date: 4/30/2013 7:14:16 PM
Corrective Plan: Information Reports are kept in the office of the FHA. No one has asked me personally for any
reports. From here out, all ADOC Information Reports will be scanned to K. Campbell for the prior month on the first
day of the current month, (to coordinate with the stats procedures), if that process is agreeable to Ms. Campbell.
Corrective Actions: See above.
6 Are there any unreasonable delays in inmate receiving prescribed medications?
Level 2 Amber User: Patricia Arroyo Date: 4/24/2013 11:22:16 AM
Corrective Plan: Acosta: Clonazepam, Dr Cleary d/c'd...medication is non-formulary. Medication was allowed to
expire.
inmate

: Benadryl RX28046749 written 05/06 good thru 06/05, inmate is currently on right now(non-formulary med)
Venlafaxine ER 150mg written 05/06 good thru 06/05, inmate is currently on right now (non-form med)

inmate

inmate

: Inmate is now in Tucson. Written 04/16/13 (Bridge) but d/c'd 04/23 (?)

: Lewis Inmate, Amitripyline written 05/06 good thru 06/05, inmate is currently on now. (non form med)

See below.

inmate

: Inmate now in Florence. Written 04/10/13 was good thru 05/09. Benadryl is non formulary med. *Status
under investigation*.
PRR ADC00520

April 2013 PHOENIX COMPLEX

inmate

: Toradol ok'd sent 04/17/13 x1 injection

inmate

: Tylenol 500mg changed to 325mg, written 04/18/13 good thru 07/17/13, inmate is currently on. Abilify, no
history, I called IDA nurse and nothing on his MAR for abilify.
CAP Revision #1 - This process is in committee, as is a statewide Corizon/Pharmacorr issue. First committee
meeting is Friday, August 2, 2013. Is not site specific.
Corrective Actions: October Action plan submitted by Corizon1.Standardized process for meds to be available to inmate upon transfer (Pharmacy Appendix 1 & 2)
2.In-service staff on process per PharmaCorr policy,
a.Agenda/sign off sheet to verify, inclusive of all pertinent staff
3.Custody educated regarding contract requirements regarding inmate transfer with meds.
4.Monitoring (Appendix I. - IV Monitoring Tools)
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 = FHA/DON/Custody/RDCQI/RVP
Continue to monitor weekly x 3 weeks, monthly until within compliance, then quarterly; monitoring frequency using
audit tool per audit results

1.Monitoring (Appendix I. - IV Monitoring Tools)
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
2.Standardized process statewide to include, but not limited to (Appendix III.1.):
a.Internal
b.External
2.In-service staff on process and ADC policy titled “Continuity of Care Upon Transfer” Chapter
5, Section 5.0 (Appendices III.2.);
a.Agenda/sign off sheet to verify, inclusive of all pertinent staff
3.Custody educated regarding contract requirements regarding inmate transfer with meds
4.Monitoring (Appendix I. - IV Monitoring Tools)
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 = FHA/DON/Custody/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.
8 Are chronic condition medication expiration dates being reviewed prior to expiration to ensure continuity
of care?
[NCCHC Standard P-D-01]
Level 2 Amber User: Kathy Campbell Date: 4/30/2013 7:14:41 PM
Corrective Plan: Problem Identified: Incomplete MARs
Discussion and Action Plan: As a result of this finding, the FHA and DON have instituted a process of confirming
that all medications currently prescribed for patients have an accurate MAR. The 26th of each month prior to the
printing of the MARs, the DON shall run a census (through AIMS) of all inmates in designated housing areas
(excluding intakes) and distribute this census to the nursing staff responsible for those areas. Nursing staff shall
then do a chart review of each patient and confirm that MARs are accurate and present in the MAR books. Nurses
shall notate on the census report if MARs are present and accurate and shall immediately correct or replace any
missing or inaccurate MARs. At the completion of this task, the census report shall be delivered back to the DON for
PRR ADC00521

April 2013 PHOENIX COMPLEX
review and a copy of this report shall be maintained in the DON's office for compliance inspection by contract
monitors. These reports shall be made available on the second Monday of each month. Inventory coordinators may
assist in this task as supervised by nursing staff.
Responsible Person: Nursing staff assigned to units for task completion. DON for review and training. FHA for
process implementation/development/direction.
Status: Initial reviews will begin immediately and the formal process is to begin August 2013. First reports with any
luck will be available on August 12th.
See below.
Corrective Actions: October Action plan submitted by Corizon1.Standardized process for meds to be available to inmate upon transfer (Pharmacy Appendix 1 & 2)
2.In-service staff on process per PharmaCorr policy,
a.Agenda/sign off sheet to verify, inclusive of all pertinent staff
3.Custody educated regarding contract requirements regarding inmate transfer with meds.
4.Monitoring (Appendix I. - IV Monitoring Tools)
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 = FHA/DON/Custody/RDCQI/RVP
Continue to monitor weekly x 3 weeks, monthly until within compliance, then quarterly; monitoring frequency using
audit tool per audit results
1.Monitoring (Appendix I. - IV Monitoring Tools)
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
2.Standardized process statewide to include, but not limited to (Appendix III.1.):
a.Internal
b.External
2.In-service staff on process and ADC policy titled “Continuity of Care Upon Transfer” Chapter
5, Section 5.0 (Appendices III.2.);
a.Agenda/sign off sheet to verify, inclusive of all pertinent staff
3.Custody educated regarding contract requirements regarding inmate transfer with meds
4.Monitoring (Appendix I. - IV Monitoring Tools)
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 = FHA/DON/Custody/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.
9 Are non-formulary requests being reviewed for approval or disapproval within 24 to 48 hours?
Level 2 Amber User: Patricia Arroyo Date: 4/24/2013 11:23:00 AM
Corrective Plan: Acosta: Clonazepam, Dr Cleary d/c'd...medication is non-formulary. Medication was allowed to
expire.
inmate

: Benadryl RX28046749 written 05/06 good thru 06/05, inmate is currently on right now(non-formulary med)
Venlafaxine ER 150mg written 05/06 good thru 06/05, inmate is currently on right now (non-form med)

inmate

: Inmate is now in Tucson. Written 04/16/13 (Bridge) but d/c'd 04/23 (?)

PRR ADC00522

April 2013 PHOENIX COMPLEX

inmate

: Lewis Inmate, Amitripyline written 05/06 good thru 06/05, inmate is currently on now. (non form med)

See Below.

inmate

: Inmate now in Florence. Written 04/10/13 was good thru 05/09. Benadryl is non formulary med. *Status
under investigation*.

inmate

: Toradol ok'd sent 04/17/13 x1 injection

inmate

: Tylenol 500mg changed to 325mg, written 04/18/13 good thru 07/17/13, inmate is currently on. Abilify, no
history, I called IDA nurse and nothing on his MAR for abilify.

CAP Revision #1 - I have emailed out to my upper management inquiring about a tool to use for a system-wide
process. We are currently using a tickler file system at Phoenix.
CAP Revision #2 - This process is in committee, as is a statewide Corizon/Pharmacorr issue. First committee
meeting is Friday, August 2, 2013.
Corrective Actions: October Action plan submitted by Corizon1.Standardized process statewide, to include but not limited to (Pharmacy Appendix 1 & 2):
a.Non-formulary process (Appendix I.1.d.)
i.Reviewed for approval within 24-48 hrs
ii.Providers notified decision within 24-48 hrs
e.Manifest Reconciliation
f.Inventory control
g.Stock Medications
h.Practitioner Cards (Appendis I.1.h.)
i.Controlled Medications (Appendix I.1.i.)
2.In-service staff
a.Using information from 8/19 - 11/13 Regional office mandatory in-service and PharmaCorr
policy
b.Agenda/sign off sheet to verify, inclusive of all pertinent staff (Appendix I.2.b.)
3.Monitoring (Appendix I. - IV Monitoring Tools)
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 = FHA/DON/IC/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.
10/11/13 Update – Statewide in Sept Redbook and MAR audit, results reviewed; to audit pharmacy in October
related to Controlled Substances and Expired meds.
10 Are providers being notified of non-formulary decisions within 24 to 48 hours?
Level 2 Amber User: Patricia Arroyo Date: 4/24/2013 11:23:11 AM
Corrective Plan: Acosta: Clonazepam, Dr Cleary d/c'd...medication is non-formulary. Medication was allowed to
expire.
inmate

: Benadryl RX28046749 written 05/06 good thru 06/05, inmate is currently on right now(non-formulary med)
Venlafaxine ER 150mg written 05/06 good thru 06/05, inmate is currently on right now (non-form med)

PRR ADC00523

April 2013 PHOENIX COMPLEX

inmate

: Inmate is now in Tucson. Written 04/16/13 (Bridge) but d/c'd 04/23 (?)

inmate

: Lewis Inmate, Amitripyline written 05/06 good thru 06/05, inmate is currently on now. (non form med)
See Below.

inmate

: Inmate now in Florence. Written 04/10/13 was good thru 05/09. Benadryl is non formulary med. *Status
under investigation*.

inmate

: Toradol ok'd sent 04/17/13 x1 injection

inmate

: Tylenol 500mg changed to 325mg, written 04/18/13 good thru 07/17/13, inmate is currently on. Abilify, no
history, I called IDA nurse and nothing on his MAR for abilify.

CAP Revision #1 - I have emailed out to my upper management inquiring about a tool to use for a system-wide
process. We are currently using a tickler file system at Phoenix.
CAP Revision #2 - This process is in committee, as is a statewide Corizon/Pharmacorr issue. First committee
meeting is Friday, August 2, 2013.
Corrective Actions: October Action plan submitted by Corizon1.Standardized process statewide, to include but not limited to (Pharmacy Appendix 1 & 2):
a.Non-formulary process (Appendix I.1.d.)
i.Reviewed for approval within 24-48 hrs
ii.Providers notified decision within 24-48 hrs
e.Manifest Reconciliation
f.Inventory control
g.Stock Medications
h.Practitioner Cards (Appendis I.1.h.)
i.Controlled Medications (Appendix I.1.i.)
2.In-service staff
a.Using information from 8/19 - 11/13 Regional office mandatory in-service and PharmaCorr
policy
b.Agenda/sign off sheet to verify, inclusive of all pertinent staff (Appendix I.2.b.)
3.Monitoring (Appendix I. - IV Monitoring Tools)
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 = FHA/DON/IC/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.
10/11/13 Update – Statewide in Sept Redbook and MAR audit, results reviewed; to audit pharmacy in October
related to Controlled Substances and Expired meds.
11 Are medication error reports being completed and medication errors documented?
Level 2 Amber User: Kathy Campbell Date: 4/30/2013 7:15:19 PM
Corrective Plan: Information Reports are kept in the office of the FHA. No one has asked me personally for any
reports. From here out, all ADOC Information Reports will be scanned to K. Campbell for the prior month on the first
day of the current month, (to coordinate with the stats procedures), if that process is agreeable to Ms. Campbell.
Information Reports would be easier managed if the Contractor could include them with the stats procedure, already
PRR ADC00524

April 2013 PHOENIX COMPLEX
in place. IRs emailed to Ms. Campbell at this time, of her request.
Corrective Actions: This has been discussed and FHA to forward medication errors as they occur. Approved.

PRR ADC00525

April 2013 PHOENIX COMPLEX

Discussion: Schedules are shared (posted) on the K-drive of the 15th of each month as requested by monitor
discussed at leadership.
Action: AFHA is concert with DON is leadership in counsel by FHA, who is responsible for recruitment.
Status: We our currently reviewing applications to improve our staffing levels.
Action: We have new hires in backgrounds, as well as continual recruitment and pending offers. Pool/prn staff and
Locums are used to cover vacancies.
Corrective Actions: See above.
3 Are all positions filled per contractor staffing pattern?
Level 2 Amber User: Helena Valenzuela Date: 4/28/2013 4:04:41 PM
Corrective Plan: Problem: Scheduling /vacancies.
Discussion: Schedules are shared (posted) on the K-drive of the 15th of each month as requested by monitor
discussed at leadership.
Action: AFHA is concert with DON is leadership in counsel by FHA, who is responsible for recruitment.
Status: We our currently reviewing applications to improve our staffing levels.
Action: We have two new hires starting this week along with 5 pending new offers.
Both new hires are providers and offers are for medical nurses and one for a nursing supervisor position. We are
working with ADOC to ensure our paper work is being filled out completely in order to obtain clearance for personnel
ASAP.
CAP Revision: MTU staffed as appropriate. Final discussion on how many nurses are needed to pass meds for 150
inmates. Please see larger complexes where nurses pass medications to 500+ inmates. Any further discussions
should be directed to Regional DON Somner.
Corrective Actions: Approved. See above.

PRR ADC00527